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Managing Activities and Exercise

Avoiding Extremes

For patients with CFS, learning to manage activity levels is a key part of managing the illness. This requires a new way of defining exercise and thinking about daily activities. Daily chores and activities, such as cleaning, errands, and hygiene, may need to be broken down into shorter, less strenuous pieces. While vigorous aerobic exercise is beneficial for many chronic illnesses, CFS patients can't tolerate traditional exercise routines. Exercise programs aimed at increasing aerobic capacity are not recommended early in therapy.

The majority of people with CFS are affected by post-exertion malaise, which is defined as intensifying of symptoms following physical or mental exertion, with symptoms typically worsening 12-48 hours after activity and lasting for days or even weeks. It's important, however, not to avoid activity and exercise altogether. Such avoidance leads to serious deconditioning and can actually worsen other symptoms. It is also important not to engage in an endless push-crash cycle in which patients do too much when they feel better, crash, rest, start to feel a little better, do too much again, and so on.

Instead, CFS patients should learn to pace activities and work with their health care professionals to create an individualized exercise program that focuses on interval activity or graded exercise. The goal is to balance rest and activity to avoid both deconditioning from lack of activity and flare-ups of illness due to overexertion. Effective activity management may help improve mood, sleep, pain, and other symptoms so patients can function better and engage in activities of daily living.

Developing an Activity Program

Start slow. It is very important that any activity plan be started slowly and increased gradually. When beginning an activity program, some CFS patients may only be able to exercise for as little as a few minutes. Patients who are severely deconditioned or who are caught in the push-crash cycle should limit themselves to the basic activities of daily living — getting up, personal hygiene, dressing, and necessary tasks — until they have stabilized.

Light, Low-impact Activity

Several daily sessions of brief, low-impact (light) activity can then be added. Simple stretching and strengthening exercise using only body weight for resistance is a good starting place for most people with CFS. All exercise needs to be followed by a rest period at a 1:3 ratio, exercising for one minute then resting for three minutes. These sessions can be slowly increased by one to five minutes a week as tolerance develops.

Daily exercise can be divided into two or more sessions to avoid symptom flare-ups. Activity should be alternating and brief, spread throughout the day and followed by rest. If patients experience a worsening of symptoms, they should return to the most recent manageable level of activity.

Strength and Conditioning Exercises

Strength and conditioning exercises are an important component of the overall activity program. Standard rehabilitative methods, such as resistance training and flexibility exercises, may help improve stamina and function, increase strength and flexibility, reduce pain, and increase range of motion.

Activity should begin slowly with simple stretching and strengthening exercises. Examples of functional exercises include repeated hand stretches, sitting and standing, wall push-ups, and picking up and grasping objects. Patients can begin with a set of two to four repetitions, building to a maximum of eight repetitions. Once this stage is mastered, resistance band exercises (using bands for strength training) can be added to build strength and flexibility. Patients should be careful to adhere to the principle of brief intervals of exercise, followed by adequate rest, to avoid post-exertion malaise.

Graded Exercise Therapy (GET)

GET is a type of physical activity therapy that starts very slowly and gradually increases over time. A GET program that includes active stretching followed by range-of-motion contractions and extensions is usually an effective start. Five minutes per day is a typical starting point for an individual who has been totally inactive. When beginning a GET program, it is important for patients to avoid extremes and instead balance physical activity and rest. Gradual, guided physical activity can help some CFS patients manage the illness. Appropriate rest is an important element of GET, and patients should learn to stop activity before illness and fatigue are worsened.

The end point of each GET session should be preset by the clock or number of repetitions, and these endpoints should be reached before the patient becomes tired. Each patient will have to determine their individual limits by trial and error; limits by time or repetition assist in this goal. Appropriate goals are to prevent tiredness, to avoid activating the syndrome, and to increase overall fitness. GET may be summarized by the adage that no exercise is bad, some is good, but too much is not helpful.

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Modifying Exercises for Severely Ill Patients

A subset of people with CFS are so severely ill that they're largely housebound or bedbound. They require special attention, including a modified approach to exercise. Hand stretches and picking up and grasping objects may be all that can be managed at first. Gradually increasing activity to the point patients can handle essential activities of daily living — getting up, personal hygiene and dressing — is the next step.

A realistic goal with severely ill patients is focusing on improving flexibility and minimizing the impact of deconditioning so they can increase function enough to manage basic activities.

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