Chapter Two, Course WB3151
Evaluating CFS and Developing Therapeutic Strategies
Once a medical provider has diagnosed CFS, the allied health professional can develop a therapeutic care plan. This plan should begin with evaluation of the impact of the illness on the individual’s quality of life and the identification of those areas of greatest need or concern to the patient. This evaluation should document existing impairment and disability to guide development of an individualized management plan and to provide a baseline against which to assess the effects of treatment.
The simplest and most effective way to evaluate CFS patients is to ask them to identify their concerns in order of importance and severity and then assess the relative impact of each on quality of life. Practitioners should employ their usual methods of evaluating the most important specific concerns and rely on their experience to develop a therapeutic plan.
Standardized and validated instruments are available to assess specific areas of impairment and to evaluate the occurrence and severity of individual symptoms in a quantitative manner. These instruments may be particularly useful to practitioners and clinics specializing in the care of people with CFS and in documenting disability for third-party providers. CDC recommends use of the Medical Outcomes Survey Short Form-36 (SF-36) (Ware and Sherbourne, 1992) to formally assess impairment and disability. This is a well-validated instrument that measures the effects of the entire illness on physical activity, social activity, usual role activities, bodily pain, general mental health, vitality and health perceptions. Considerable normative data are available for many illnesses, including CFS. The SF-36 is proprietary; however, a clinical version, the Rand-36, is freely available to any practitioner. CDC recommends use of the recently validated CDC Symptom Inventory (Wagner et al., 005) to assess the impact of CFS case-defining and other symptoms. The instrument has been used in studies of CFS, other fatiguing illness and nonfatigued controls identified in the general population. It will be freely available from CDC and scoring is straightforward. Finally, the Multidimensional Fatigue Inventory (MFI) (Smets et al., 1995) can be used to quantify the level of fatigue and its consequences. All three instruments are self-administered by patients and can be completed in a relatively short time period. Use of this battery of tests follows the recommendations of the CDC’s empirical approach to CFS definition (Reeves et al., 2005). 
Appendix A (PDF – 149 KB) includes additional information on these assessment tools.
There are other tools that address specific areas of impairment, for instance, a visual pain rating scale is an efficient method for documenting levels of pain in specific areas (see Appendix A [PDF – 149 KB]). Standard tests of strength and flexibility, such as grip strength (e.g., hand dynamometry), sit-and-reach, muscle flexibility (e.g., goniometry) and consecutive sit-to-stand repetitions in 30 seconds should be done when applicable (Karper and Stasik, 2003; ACSM, 2000).
Exercise testing may be indicated to evaluate deconditioning. People with CFS should be advised to avoid other activities on the day testing is scheduled because symptoms will likely be exacerbated (Bailey, 2003). The following types of questions can be helpful in assessing people with CFS before, during and after activity/exercise sessions that are designed for rehabilitation.
- At the initial appointment: What is a typical day like for you since becoming ill? What activities do you do? What are your three greatest problems or concerns? What are your goals for therapy?
- During the rehabilitation session: How hard are you working? [Use the Borg or other perceived exertion scale, (U.S. Centers for Disease Control and Prevention, 2006, Instructions for Borg Rating of Perceived Exertion Scale).] How are you feeling?
- The day after the session: Ask patients to call you 24 hours after the appointment to report how they are feeling. This helps the provider assess whether the activity provoked an exacerbation of illness and should be modified.
- At the next session: How did you feel after the last session? If home-based exercise or activity was prescribed, were you able to do it? How did you feel during and afterward? What other activities did you do on the day(s) you did rehabilitation? (An activity diary, described below, can be a helpful adjunct to this direct patient report.)
In an activity diary, people with CFS are asked to briefly chart their daily activities and health status. This can be important in assessing activity and its impact on function, symptoms and health. A diary may reveal patterns of activity that exacerbate symptoms, and this can be changed to promote better function. However, such diaries may reinforce symptom focusing, which may cause some patients to feel worse, and subsequently the diary serves to undermine therapeutic efforts that are designed to change certain behavior patterns. Activity and symptom diaries may be very effective during early phases of the therapy process, but become less effective or more difficult to maintain during later phases of therapy. Therapists should use sound clinical judgment and consider issues of client appropriateness, treatment goals and timing when utilizing activity and symptom diaries.
Many practitioners have developed their own means of assessing symptoms and disability. Practitioners are encouraged to rely on their clinical experience because there are currently no standardized guidelines for monitoring or managing CFS.
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Content Source: National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ZVED)