Activity management based on 2-day cardiopulmonary exercise testing results

The results from a two-day cardiopulmonary exercise test can help ME/CFS patients manage their activity levels in order to minimize post-exertional malaise (PEM).

Theory

In "Conceptual model for physical therapist management of chronic fatigue syndrome/myalgic encephalomyelitis" by Todd E. Davenport, Staci R. Stevens, Mark J. VanNess, Christopher R. Snell, and Tamara Little, recommendations are divided into two categories: pacing self-management and therapeutic exercise.

Pacing self-management focuses on staying below the anaerobic threshold (AT) heart rate, as determined by a 2-day CPET. Strategies include wearing a heart rate monitor, frequent breaks including diaphragmatic breathing, alternate positions, and use of adaptive equipment, and keeping an activities log to further identify activities that induce post-exertional malaise PEM.

Therapeutic exercise is designed to prevent excessive use of the aerobic respiration system. They recommend starting with stretching and active range of motion exercises. When these are well tolerated without triggering PEM, the patient can move on to strength training: short duration, low intensity strengthening exercises with adequate rest intervals. Finally, patients can advance to short duration, low intensity interval training. Patients who can tolerate this can move on to short-duration aerobic interval training.

In all these stages, interval duration should be under 2 minutes, and the heart rate kept at 10% below the AT. The paper stresses caution and slow changes, as tolerated.

In the absence of 2-day CPET results, they suggest 3 methods of estimating the anaerobic threshold (AT) heart rate:

• estimating the AT from V̇O2 Max measurements obtained during submaximal exercise testing;
• the heart rate corresponding to Borg Rating of Perceived Exertion ratings of 13 to 15 during submaximal exercise testing may be used.
• estimating the heart rate at AT by calculating 55% of the HR at the V̇o2max as a starting point, although specific establishment of the HR at the AT in this population requires additional research. In the general population, this is calculated by the formula (220-age) * 0.55.

In "Functional Outcomes of Anaerobic Rehabilitation in a Patient with Chronic Fatigue Syndrome" by Staci Stevens and Todd Davenport recommendations for an ME/CFS patient were again divided into two categories, pacing self-management and therapeutic exercise.

Pacing self-management focused on keeping the heart rate below the ventilatory threshold, and using diaphragmatic breathing.

Restorative strengthening and flexibility exercises were recommended as follows:

• keeping the heart rate below the AT;
• 3 times weekly;
• exercises were done lying down

At the one year follow-up, the patient showed 75% improvement in the time it took her to recover from the 2-day CPET itself. She also reported increased ability to complete daily activities.

Evidence

• Case report on one-year follow-up of patient who was given a rehabilitation program after a 2-day CPET, and descriptive article by Cort Johnson on the study, providing additional information

Clinicians

• Staci Stevens at the Workwell Foundation, California, US.
• Betsy Keller at Ithaca College, New York, US.

Risks & safety

Although the Institute of Medicine (IOM) report states that 2-day CPET is very reliable to objectively measure post-exertional malaise PEM, the IOM committee emphasized "that the CPET is not required to diagnose patients with ME/CFS. Further, this test carries substantial risk for these patients as it may worsen their condition (Nijs et al., 2010; VanNess et al., 2010)."

Costs & availability

2-day CPET testing is available at the following locations:

• Workwell Foundation (California, United States)
• Betsy Keller at Ithaca College (New York, United States) - Cost is $2200. Because they are based in a college setting (not healthcare setting), they cannot process insurance (including Medicare or Medicaid), so the patient would need to work directly with their insurer about reimbursement.
• Charles Lapp at the Hunter-Hopkins Center in Charlotte, NC
• Laura Black in the Hunter-Hopkins Center in Charlotte, NC

See also

• Two-day cardiopulmonary exercise test (2-day CPET)
• Activity monitor

post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive exertions. PEM may be referred to as a "crash" or "collapse" and can last for days or weeks. Symptoms can include cognitive impairments, muscle pain, trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, and others.

See post-exertional malaise.

pacing The practice of staying within one's "energy envelope" or personal limit by combining periods of activity with periods of rest or avoiding exerting beyond a certain level. ME/CFS patients use pacing to avoid or reduce post-exertional malaise (PEM). Some patients use a heart rate monitor to help with pacing.

(HR) - the number of times the heart beats within a certain time period, usually a minute

heart rate (HR) - the number of times the heart beats within a certain time period, usually a minute

heart rate (HR) - the number of times the heart beats within a certain time period, usually a minute

two-day cardiopulmonary exercise test (CPET) - A diagnostic test which involves testing an ME/CFS patient exercising on an exercise machine, while monitoring their respiration, especially oxygen consumption. This test is repeated the following day in order to confirm the patient's inability to replicate the first-day performance. This test is thought to be the most objective way to detect post-exertional malaise.

See two-day cardiopulmonary exercise test.

National Academy of Medicine (NAM) - An American non-profit, non-governmental organization which provides expert advice to governmental agencies on issues relating to biomedical science, medicine and health. Formerly known as the Institute of Medicine (IOM).

See National Academy of Medicine.

See myalgic encephalomyelitis.

See chronic fatigue syndrome.

National Academy of Medicine (NAM) - An American non-profit, non-governmental organization which provides expert advice to governmental agencies on issues relating to biomedical science, medicine and health. Formerly known as the Institute of Medicine (IOM).

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.