Two-day cardiopulmonary exercise test

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Two-day cardiopulmonary exercise test or 2-day CPET is a procedure which assesses exercise capacity and recovery by performing two exercise tests 24 hours apart.[1] The hypothesis is that ME/CFS patients display a characteristic deterioration in exercise capacity on the second test, a finding that has been reported by multiple research groups.[2][3][4]
Photo of a woman walking on a treadmill while wearing a clear mask over her nose and mouth, and attached to a cart holding medical equipment.
Cardiopulmonary Exercise Test
The maximal, symptom-limited cardiopulmonary exercise test (CPET) is considered the gold standard for measuring physical capacity.[5][6] It is commonly used to measure the fitness level of athletes, as well as patients with cardiopulmonary disease.[7] In these populations, CPET measures are highly reliable and reproducible.[1] Exercise physiologists however have noted that ME/CFS patients are unable to reproduce these measurements, despite meeting criteria for maximal effort.[8] According to a 2015 report by The National Academy of Medicine, “ME/CFS patients have significantly lower results on CPET 2 than on CPET 1 on one or more of the following parameters: VO2max, VO2 at ventilatory threshold and maximal workload or workload at ventilatory threshold.”[9] 

According to researchers in the field, the abnormal results of ME/CFS patients on the 2-day CPET reflect post-exertional malaise, a marked symptom exacerbation after exercise thought to be characteristic of this condition.[2] The 2015 report by National Academy of medicine indicated that the 2-day CPET protocol can be used as an objective indicator that physical exertion decreases subsequent function in patients with ME/CFS, for example in obtaining  social security disability.[9] The 2-day CPET protocol however is not required in making the diagnosis of ME/CFS. Some have expressed concern that exercise tests may significantly worsen the condition of ME/CFS patients.[9][10][11][4]

Evidence[edit | edit source]

Mark VanNess, Christopher Snell and Staci Stevens of the University of the Pacific, were the first to study the two-day CPET procedure in patients with ME/CFS. In a 2007 study published in the Journal of Chronic Fatigue Syndrome, they compared six ME/CFS patients with six controls. At the first CPET there were no major differences between the two groups. At the second CPET however, ME/CFS patients reached significantly lower peak oxygen consumption and oxygen consumption at aerobic threshold.[8]

In 2010 a Dutch research group including Ruud Vermeulen and Frans Visser used the 2-day CPET in a study with 15 female ME/CFS and 15 healthy controls. Patients reached the aerobic threshold and the maximal exercise at much lower oxygen consumption than controls, an effect that was magnified during the second-day exercise test. Since levels of creatinine kinase in the blood and oxidative phosphorylation in mononuclear cells were normal in patients before and after exercise, Vermeulen et al. speculated that the lowered anaerobic threshold was not so much a result of mitochondrial insufficiency, but of impaired oxygen transport to the muscles.[12]

In 2013 Snell, Stevens and VanNess tested the 2-day CPET procedure in a larger sample of 51 ME/CFS patients and 10 heathy controls. Once again, there were no sufficient differences between the groups at the first CPET. During the exercise test on the second day however, ME/CFS patients showed much lower oxygen consumption and workload at peak exercise and at aerobic threshold. Group differences were not due to lack of effort since most participants attained the ventilatory threshold and achieved a respiratory exchange ratio of greater than or equal to 1.1.[4]

In 2014 the research group of Betsy Keller used the 2-day CPET protocol in a study involving 22 ME/CVS patient. A decline on several physiological measures was found (see table), while the respiratory exchange ratio indicated maximum efforts by participants during both exercise tests.[2]

This group followed this research up with a study of a single pair of monozygotic twins in 2016.[13]

Physiological changes between first and second exercise test during 2-day CPET procedure in patients with ME/CFS 
Number of ME/CFS patients VO2 peak VO2 at VT Workload peak Workload at VT HR peak O2pulse at VT
VanNess et al. 2007. 6 -22% -26% ? ? ? ?
Vemeulen et al. 2010.  15 -6.3% -7.0% -5.3% -7.0% -1.9% -8.8%
Snell et al. 2013. 51 -5% -10.8% -7.2% -55.2% ? ?
Keller et al. 2014. 22 -13.8% -15.8% -12.5% -21.3% -5.9% -12.6%
Giloteaux et al. 2016. 1 (monozygotic twin) 0% -13.4% 0% -25% +7.4% ?
Hodges et al. 2017. 10 +5.3% +6.1% -6.7% -11.4% -0.6% ?
Nelson et al. 2019. 16 +0.4% -3.1% -1.2% -17.4% -0.5% ?
Lien et al. 2019. (numerical estimates) 18 -5% -6% -2% -7% +1.5% ?
In 2017, a research team form New Zealand compared the physiological responses during a 2-day CPET, in ten patients with ME/CFS, seven patients with MS and seventeen healthy controls. Curiously peak oxygen increased at the second exercise test in ME/CFS patients, but there was a significant reduction noticeable in workload at aerobic threshold, a decline that was not seen in MS-patients or healthy controls.  According to the authors:
“differences between MS and CFS/ME responses only became evident after a second maximal exercise test, thus suggesting that a repeated protocol is required to not only distinguish CFS/ME from HC, but also from other fatigue-related conditions, who may not suffer from postexertional malaise and have a differing delayed fatigue profile.”[3]
In a 2019 the 2-day CPET procedure was tested by an Australian research team of Nelson and colleagues. They found a significant larger reduction in workload at the ventilatory treshold in patients with ME/CFS compared to healthy controls. A percentage change of −6.3% to −9.8% provided good sensitivity and specificity, indicating this test has the potential to become a biomarker for ME/CFS. However, the sample size of this study was small (16 ME/CFS paitients), the control group consisted only of healthy persons (instead of patients with other chronic illnesses) and no significant difference was found in VO2 at the ventilatory threshold.[14]

A small Norwegian study also reported a significant larger reduction in workload at the ventilatory treshold in 18 patients with ME/CFS compared to healthy controls, although this was not the case for peak values or VO2 measurement at the ventilatory threshold. The authors also measured arterial lactate concentrations, every 30 seconds during the exercise tests. Lactate was higher per power output per kg in patients than controls and the differences increased significantly at the second exercise test. In the healthy controls lactate concentration at the ventilatory threshold decreased while this was not the case in ME/CFS patients,suggesting a problem in lactate clearance ability.[15]

Unpublished studies have reported negative results for the repeated CPET procedure. A thesis[16] by Nielsen TM at the Massey University, New-Zealand, performed the second exercise test 48 hours and 72 hours later, instead of the usual 24 hours. The study did not find significant reductions of workload at the ventilatory threshold in ME/CFS patients compared to controls. The 8 ME/CFS patients in the 72 hours group had a workload at ventilatory threshold that was slightly higher instead of lower than during the first test. In a 2018 presentation[17] Ruud Vermeulen reported to have data on approximately 500 ME/CFS patients who performed the repeated CPET procedure. He stated the test on the second day did not show any difference in VO2Max compared to the first day, as shown in the graphs he presented.

Use as a Biomarker[edit | edit source]

Snell et al. suggested 2-day CPET could be used "diagnostically as an objective indicator of an abnormal postexertion response and possibly even a biomarker for the condition"[4]. Using the data from the two exercise tests, their research team was able to correctly classify 95% of the total sample, as a patient or healthy control.

While a unique reduction in physiological capacity was observed in ME/CFS by several studies and different research groups, sample sizes were rather small and disagreement exists on which physiological measure accurately displayed ME/CFS patients’ abnormal exertional response.[2]

Another objection to the 2-day CPET as a biomarker for ME/CFS was raised by Snell et al themselves. They suggested it might be unethical[4] to use this method to detect ME/CFS patients since many of these patients might suffer relapse as a result of exercise testing. In their 2010 study, 60% of ME/CFS patients reported that it took them more than 5 days to recover from a single (maximal) CPET. It is therefore possible that in some ME/CFS patients a 2-day CPET might cause a long-lasting relapse. Science-reporter and ME/CFS patient Simon McGrath for example wrote: “You couldn’t pay me enough money to take even one max test. My last relapse, which took me nearly 2 years to get over, happened after way less than maximal exertion – a 2-day test is not for everyone."[18]

Others have noted that the CPET-procedure is not very practical. It cannot be used in patients with severe ME/CFS (thus excluding these patients from study) and because of cost and expertise, it may not be available to most clinicians.[19] CPET for ME/CFS is usually not covered by insurance and can cost hundreds of dollars.[20] For these reasons PEM is commmonly assessed using self-reporting questionnaires. 

Brian Vastag was able to prove his PEM was a severe symptom causing disability with CPET winning his long term disability (LTD) claim.[21]

Cost and availability[edit | edit source]

Talks and interviews[edit | edit source]

See also[edit | edit source]

Learn more[edit | edit source]

References[edit | edit source]

  1. 1.01.1 Stevens, Staci; Snell, Chris; Stevens, Jared; Keller, Betsy; VanNess, J. Mark (2018). "Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Frontiers in Pediatrics. 6: 242. doi:10.3389/fped.2018.00242. ISSN 2296-2360. PMC 6131594Freely accessible. PMID 30234078. 
  2. 2.02.12.22.3 Keller, Betsy A.; Pryor, John Luke; Giloteaux, Ludovic (Apr 23, 2014). "Inability of myalgic encephalomyelitis/chronic fatigue syndrome patients to reproduce VO₂peak indicates functional impairment". Journal of Translational Medicine. 12: 104. doi:10.1186/1479-5876-12-104. ISSN 1479-5876. PMC 4004422Freely accessible. PMID 24755065. 
  3. 3.03.1 Hodges, L. D.; Nielsen, T.; Baken, D. (Jul 2018). "Physiological measures in participants with chronic fatigue syndrome, multiple sclerosis and healthy controls following repeated exercise: a pilot study". Clinical Physiology and Functional Imaging. 38 (4): 639–644. doi:10.1111/cpf.12460. ISSN 1475-097X. PMID 28782878. 
  4. 4.04.14.24.34.4 Snell, C. R.; Stevens, S. R.; Davenport, T. E.; Van Ness, J. M. (Jun 27, 2013). "Discriminative Validity of Metabolic and Workload Measurements for Identifying People With Chronic Fatigue Syndrome". Physical Therapy. 93 (11): 1484–1492. doi:10.2522/ptj.20110368. ISSN 0031-9023. 
  5. Chandra, Divay; Wise, Robert A.; Kulkarni, Hrishikesh S.; Benzo, Roberto P.; Criner, Gerard; Make, Barry; Slivka, William A.; Ries, Andrew L.; Reilly, John J. (Dec 2012). "Optimizing the 6-Min Walk Test as a Measure of Exercise Capacity in COPD". Chest. 142 (6): 1545–1552. doi:10.1378/chest.11-2702. ISSN 0012-3692. PMC 3515028Freely accessible. PMID 23364913. 
  6. Demir, Rengin; Küçükoğlu, Mehmet Serdar (Dec 2010). "Evaluation of exercise capacity in pulmonary arterial hypertension". Turk Kardiyoloji Dernegi Arsivi: Turk Kardiyoloji Derneginin Yayin Organidir. 38 (8): 580–588. ISSN 1016-5169. PMID 21248462. 
  7. Albouaini, Khaled; Egred, Mohaned; Alahmar, Albert; Wright, David Justin (Nov 2007). "Cardiopulmonary exercise testing and its application". Postgraduate Medical Journal. 83 (985): 675–682. doi:10.1136/hrt.2007.121558. ISSN 1469-0756. PMC 2734442Freely accessible. PMID 17989266. 
  8. 8.08.1 Vanness, J. Mark; Snell, Christopher R.; Stevens, Staci R. (Jan 2007). "Diminished Cardiopulmonary Capacity During Post-Exertional Malaise". Journal of Chronic Fatigue Syndrome. 14 (2): 77–85. doi:10.1300/j092v14n02_07. ISSN 1057-3321. 
  9. 9.09.19.2 Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; Board on the Health of Select Populations; Institute of Medicine (2015). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. The National Academies Collection: Reports funded by National Institutes of Health. Washington (DC): National Academies Press (US). ISBN 9780309316897. PMID 25695122. 
  10. Nijs, J.; Van Oosterwijck, J.; Meeus, M.; Lambrecht, L.; Metzger, K.; Frémont, M.; Paul, L. (Apr 2010). "Unravelling the nature of postexertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome: the role of elastase, complement C4a and interleukin-1beta". Journal of Internal Medicine. 267 (4): 418–435. doi:10.1111/j.1365-2796.2009.02178.x. ISSN 1365-2796. PMID 20433584. 
  11. VanNess, J. Mark; Stevens, Staci R.; Bateman, Lucinda; Stiles, Travis L.; Snell, Christopher R. (Feb 2010). "Postexertional malaise in women with chronic fatigue syndrome". Journal of Women's Health (2002). 19 (2): 239–244. doi:10.1089/jwh.2009.1507. ISSN 1931-843X. PMID 20095909. 
  12. Vermeulen, Ruud C. W.; Kurk, Ruud M.; Visser, Frans C.; Sluiter, Wim; Scholte, Hans R. (Oct 11, 2010). "Patients with chronic fatigue syndrome performed worse than controls in a controlled repeated exercise study despite a normal oxidative phosphorylation capacity". Journal of Translational Medicine. 8: 93. doi:10.1186/1479-5876-8-93. ISSN 1479-5876. PMC 2964609Freely accessible. PMID 20937116. 
  13. Giloteaux, Ludovic; Hanson, Maureen R.; Keller, Betsy A. (Oct 10, 2016). "A Pair of Identical Twins Discordant for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Differ in Physiological Parameters and Gut Microbiome Composition". American Journal of Case Reports. 17: 720–729. doi:10.12659/AJCR.900314. ISSN 1941-5923. PMC 5058431Freely accessible. PMID 27721367. 
  14. Nelson, Maximillian J.; Buckley, Jonathan D.; Thomson, Rebecca L.; Clark, Daniel; Kwiatek, Richard; Davison, Kade (Mar 14, 2019). "Diagnostic sensitivity of 2-day cardiopulmonary exercise testing in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Journal of Translational Medicine. 17 (1): 80. doi:10.1186/s12967-019-1836-0. ISSN 1479-5876. PMC 6417168Freely accessible. PMID 30871578. 
  15. Lien, Katarina; Johansen, Bjørn; Veierød, Marit B.; Haslestad, Annicke S.; Bøhn, Siv K.; Melsom, Morten N.; Kardel, Kristin R.; Iversen, Per O. (2019). "Abnormal blood lactate accumulation during repeated exercise testing in myalgic encephalomyelitis/chronic fatigue syndrome". Physiological Reports. 7 (11): e14138. doi:10.14814/phy2.14138. ISSN 2051-817X. 
  16. Nielsen TM. The Timeline of Post Exertional Malaise in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. 2018.
  17. Presentation Ruud Vermeulen (03-06-2018). Minute 34.00.
  18. "Declining Production: Exercise Study Reveals Broad Declines in Energy Output in Chronic Fatigue Syndrome - Health Rising". Health Rising. May 20, 2014. Retrieved Aug 17, 2018. 
  19. https://www.commondataelements.ninds.nih.gov/Doc/MECFS/03_Fatigue_Subgroup_CDE_Draft_Recommendations.pdf
  20. Cotler, Joseph; Holtzman, Carly; Dudun, Catherine; Jason, Leonard A. (Sep 11, 2018). "A Brief Questionnaire to Assess Post-Exertional Malaise". Diagnostics (Basel, Switzerland). 8 (3). doi:10.3390/diagnostics8030066. ISSN 2075-4418. PMID 30208578. 
  21. 21.021.1 Tillman, Adriane (Jun 4, 2018). "Victory for ME Disability Claim - U.S. Court Upholds Plaintiff's Lawsuit After Being Denied Disability". #MEAction. Retrieved Feb 2, 2019. 

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Myalgic encephalomyelitis or chronic fatigue syndrome, often used when both illnesses are considered the same.

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From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history.