title: Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome Functional status of persons with chronic fatigue syndrome in the Wichita, Kansas, population Exercise performance and chronic pain in chronic fatigue syndrome: the role of pain catastrophizing. Therapist effects in routine psychotherapy practice: An account from chronic fatigue syndrome Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments Can pacing self-management alter physical behavior and symptom severity in chronic fatigue syndrome? A case series. Measuring disability in patients with chronic fatigue syndrome: reliability and validity of the Work and Social Adjustment Scale. How relevant are exercise capacity measures for evaluating treatment effects in chronic fatigue syndrome? Results from a prospective, multidisciplinary outcome study Disability evaluation in chronic fatigue syndrome: associations between exercise capacity and activity limitations/participation restrictions Can exercise limits prevent post-exertional malaise in chronic fatigue syndrome? An uncontrolled clinical trial Functional status in patients with chronic fatigue syndrome, other fatiguing illnesses, and healthy individuals. Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up Functional Incapacity and Physical and Psychological Symptoms: How They Interconnect in Chronic Fatigue Syndrome Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. The relation of sleep difficulties to fatigue, mood and disability in chronic fatigue syndrome. Breathing retraining in patients with chronic fatigue syndrome: A pilot study Effectiveness of stepped care for chronic fatigue syndrome: a randomized noninferiority trial. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. Implementing a minimal intervention for chronic fatigue syndrome in a mental health centre: a randomized controlled trial. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme. Kinesiophobia in chronic fatigue syndrome: assessment and associations with disability.
abstract: Abstract Objective : To assess the efficacy of an educational intervention explaining symptoms to encourage grade d exercise in patients with chronic fatigue syndrome . Design : R and omised controlled trial . Setting : Chronic fatigue clinic and infectious diseases outpatient clinic . Subjects : 148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome . Interventions : Patients r and omised to the control group received st and ardised medical care .  Patients r and omised to intervention received two individual treatment sessions and two telephone follow up calls , supported by a comprehensive educational pack , describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based grade d exercise . The minimum intervention group had no further treatment , but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months . Main outcome measure : A score of 25 or an increase of 10 on the SF-36 physical functioning subscale ( range 10 to 30 ) 12 months after r and omisation . Results : 21 patients dropped out , mainly from the intervention groups . Intention to treat analysis showed 79 ( 69 % ) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two ( 6 % ) of controls , who received st and ardised medical care ( P<0.0001 ) . Similar improvements were observed in fatigue , sleep , disability , and mood . No significant differences were found between the three intervention groups . Conclusions : Treatment incorporating evidence based physiological explanations for symptoms  was effective in encouraging self managed grade d exercise . This result ed in substantial improvement compared with st and ardised medical care Background Scant research has adequately addressed the impact of chronic fatigue syndrome on patients ' daily activities and quality of life . Enumerating specific problems related to quality of life in chronic fatigue syndrome patients can help us to better underst and and manage this illness . This study addresses issues of functional status in persons with chronic fatigue syndrome and other fatiguing illnesses in a population based sample , which can be generalized to all persons with chronic fatigue . Methods We conducted a r  and om telephone survey in Wichita , Kansas to identify persons with chronic fatigue syndrome and other fatiguing illnesses . Respondents reporting severe fatigue of at least 1 month 's duration and r and omly selected non-fatigued respondents were asked to participate in a detailed telephone interview . Participants were asked about symptoms , medical and psychiatric illnesses , and about physical , social , and recreational functioning . Those meeting the 1994 chronic fatigue syndrome case definition , as determined on the basis of their telephone responses , were invited for clinical evaluation to confirm a diagnosis of chronic fatigue syndrome . For this analysis , we evaluated  unemployment due to fatigue , number of hours per week spent on work , chores , and other activities ( currently and prior to the onset of fatigue ) , and energy level .  Results There was no difference between persons with chronic fatigue syndrome and persons with a chronic fatigue syndrome-like illness that could be explained by a medical or psychiatric condition for any of the outcomes we measured except for unemployment due to fatigue ( 15 % vs. 40 % , P < .01 ) . Persons with chronic fatigue syndrome and other fatiguing illnesses had substantially less energy and spent less time on hobbies , schooling , or volunteer work than did non-fatigued controls ( P < .01 ) . Conclusions Persons with chronic fatigue syndrome are as impaired as persons whose fatigue could be explained by a medical or psychiatric condition , and they have less energy than non-fatigued controls OBJECTIVES This study aim ed to examine the associations between bodily pain , pain catastrophizing , depression , activity limitations /participation restrictions , employment status , and exercise performance in female patients with chronic fatigue syndrome ( CFS ) who experience widespread pain . DESIGN Cross-sectional observational study . SETTING A university-based clinic . PATIENTS Thirty-six female CFS patients who experienced widespread pain . OUTCOME MEASURES Patients filled in the  Medical Outcomes Short-Form 36 Health Status Survey ,  the  Chronic Fatigue Syndrome Activities and Participation Question naire , the Beck Depression Inventory , and the Pain Catastrophizing Scale , and underwent a maximal exercise stress test with continuous monitoring of electrocardiographic and ventilatory parameters . RESULTS Pain catastrophizing was related to bodily pain ( r = -0.70 ) , depression ( r = 0.55 ) , activity limitations /participation restrictions ( r = 0.68 ) , various aspects of quality of life ( r varied between -0.51 and -0.64 ) , and exercise capacity ( r varied between -0.41 and -0.61 ) . Based on hierarchical multiple regression analysis , pain catastrophizing accounted for 41 % of the variance in bodily pain in female CFS patients who experience chronic widespread musculoskeletal pain . Among the three subscale scores of the Pain Catastrophizing Scale , helplessness and rumination rather than magnification were strongly related to bodily pain . Neither pain catastrophizing nor depression was related to employment status . CONCLUSIONS These data provide evidence favoring a significant association between pain catastrophizing , bodily pain , exercise performance , and self-reported disability in female patients with CFS who experience widespread pain . Further prospect i ve longitudinal study ing of these variables is required Abstract The effect of therapists in psychotherapy is a much debated topic , with a number of studies showing therapist variance being large while other studies show little or no variability in outcomes due to therapists . The aim of this study was to investigate therapist effects in a well-defined sample of patients and therapists from an outpatient service which specializes in providing cognitive behaviour therapy ( CBT ) for patients with chronic fatigue syndrome ( CFS ) . Therapy was provided in a highly specialized clinical setting for CFS and was delivered by qualified CBT therapists with at least 2 years experience with this client group . Three hundred and seventy-four patients with CFS and 12 cognitive behavioural psychotherapists took part .  Therapist effects on the primary outcomes of fatigue and disability were investigated with multilevel r and om effects models and variance component analysis . Different models were computed and compared . Results showed a reduction in fatigue and disability scores after therapy . Variance explained by therapists , when demographic covariates were accounted for , was 0 % for fatigue and under 2 % for disability . A number of important factors may have played a significant role in minimizing therapist effects in our study . These are : specialist setting , single centre , patients with the same primary diagnosis , therapists of the same orientation and training , shared environment and supervision . Future studies may stress the importance of these factors in the investigation of the therapist effect in psychotherapy Abstract Objective : To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome . Design : R and omised controlled trial with final assessment at 12 months . Setting : An infectious diseases outpatient clinic . Subjects : 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome . Interventions : Medical care comprised assessment , advice , and follow up in general practice . Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care . Main outcome measures : The proportions of patients ( a ) who achieved normal daily functioning ( Karnofsky score 80 or more ) and ( b ) who achieved a clinical ly significant improvement in functioning ( change in Karnofsky score 10 points or more ) by 12 months after r and omisation . Results : Only two eligible patients refused to participate . All r and omised patients completed treatment . An intention to treat analysis showed that 73 % ( 22/30 ) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27 % ( 8/30 ) of patients who were given only medical care ( difference 47 percentage points ; 95 % confidence interval 24 to 69 ) . Similar differences were observed in subsidiary outcome measures . The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy . Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone . Conclusion : Adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment . Key messages Key messages There is no generally accepted form of treatment New findings show that patients referred to hospital for the chronic fatigue syndrome have a better outcome if they are given a course of cognitive behaviour therapy than if they receive only basic medical care Clinical improvement with cognitive behaviour therapy may be slow but often continues after treatment has ended Cognitive behaviour therapy should be considered as an option for patients presenting with the chronic fatigue Objectives For the measurement of  patient-reported outcomes , such as ( health-related ) quality of life , often many measurement instruments exist that intend to measure the same construct . To facilitate instrument selection , our aim was to develop a highly sensitive search filter for finding studies on measurement properties of measurement instruments in PubMed and a more precise search filter that needs less abstract s to be screened , but at a higher risk of missing relevant studies . Methods A r and om sample of 10,000 PubMed records ( 01 - 01 - 1990 to 31 - 12 - 2006 ) was used as a gold st and ard . Studies on measurement properties were identified using an exclusion filter and h and search ing . Search terms were selected from the relevant records in the gold st and ard as well as from 100 systematic review s of measurement properties and combined based on sensitivity and precision . The performance of the filters was tested in the gold st and ard as well as in two validation sets , by calculating sensitivity , precision , specificity , and number needed to read . Results We identified 116 studies on measurement properties in the gold st and ard . The sensitive search filter was able to retrieve 113 of these 116 studies ( sensitivity 97.4 % , precision 4.4 % ) . The precise search filter had a sensitivity of 93.1 % and a precision of 9.4 % . Both filters performed very well in the validation sets . Conclusion The use of these search filters will contribute to evidence -based selection of measurement instruments in all medical fields Given the lack of evidence in support of pacing self-management for patients with chronic fatigue syndrome ( CFS ) , we examined whether physical behavior and health status of patients with CFS would improve in response to a pacing self-management program . We performed an observational study of pacing self-management in seven CFS patients using a single-case study design . Stages A1 and A2 ( 7-day assessment periods ) of the A1-B-A2 design corresponded to the baseline and posttreatment measurements of physical behavior ( real-time activity monitoring ) and health status ( self-reported measures ) , respectively . Stage B ( 3 weeks of treatment ) consisted of three individual treatment sessions of pacing self-management . When comparing pre- versus posttreatment data , we found that the patients ' ability to perform daily activities and the severity of their symptom complexes were improved ( p = 0.043 ) . Concentration difficulties , mood swings , muscle weakness , and intolerance to bright light improved as well . A statistically significant decrease in the mean time spent doing light activity ( <3 metabolic equivalents ) was observed , but a change in the way physical activity was spread throughout the day was not . We found that 3 weeks of pacing self-management was accompanied by a modest improvement in symptom severity and daily functioning . The outcome of the present study calls for a r and omized controlled clinical trial to examine the effectiveness of pacing self-management for people with CFS BACKGROUND Disability is a defining feature of chronic conditions , and it is an increasingly used measure of therapy effectiveness . The  Work and Social Adjustment Scale ( WSAS )  is a simple and clear measure of disability . Although the scale is widely used , no study has yet investigated its psychometric properties in patients with chronic fatigue syndrome ( CFS ) . METHODS Data from two sample s of patients were used , one from a multicenter r and omized controlled clinical trial of treatments for CFS ( n = 639 ) and the other from a clinic that specializes in CFS ( n=384 ) . All patients completed the WSAS as well as other measures . RESULTS Internal consistency and the Spearman-Brown split-half coefficient values indicated that the scale is reliable . CFS patients who had comorbid diagnoses of depression , anxiety or fibromyalgia had higher WSAS scores . High levels of disability were associated with high number of physical symptoms , severe fatigue , depression , anxiety , poor sleep quality and poor physical fitness , with correlation coefficients ranging between 0.41 and 0.11 . Lower scores on the WSAS were modestly associated with better physical functioning as well as higher levels of physical capacity as assessed by a walking test . Sensitivity to change was evaluated in a subgroup of patients who had undergone a course of cognitive behavioral therapy .  Disability significantly decreased after therapy and remained stable at follow-ups . CONCLUSION The WSAS is a reliable and valid assessment tool for disability in patients with CFS Objective : To evaluate the outcome of a multidisciplinary treatment programme for patients with chronic fatigue syndrome , including health-related quality of life ( HRQoL ) and psychosocial variables , and exercise capacity measures . Design : A six-month prospect i ve outcome study . Setting : University outpatient rehabilitation clinic ; group setting . Subjects : One hundred and sixteen women fulfilling chronic fatigue syndrome criteria . Interventions : Cognitive behaviourally and grade d exercise-based strategies ; emphasis on adaptive lifestyle changes . Measures : Short Form General Health Survey ( SF-36 ) ; Symptom Checklist ( SCL-90 ) ; Causal Attribution List ( CAL ) ; Self-Efficacy Scale ( SE ) ; maximum progressive bicycle ergometer test with respiratory gas analysis ; and isokinetic leg strength test  , before and after treatment . Results : The total group significantly improved on nearly all reported HRQoL/ psychosocial variables . Changes in exercise capacity measures were rather modest and did not correlate or only weakly correlated with HRQoL/psychosocial variables . Subgroup analyses indicated that less fit patients improved significantly more on exercise capacity measures than their more fit counterparts . Patients who were fitter at baseline scored better on pretreatment HRQoL/psychosocial variables , but both subgroups improved similarly on these variables . Conclusions : Health-related quality of life and psychosocial functioning in patients with chronic fatigue syndrome improves after a six-month cognitive behaviourally and grade d exercise-based multidisciplinary treatment programme . Increase in exercise capacity measures is not a necessary condition for reported improvements , except for less fit patients Objective : In an attempt to examine whether impairments in cardiorespiratory fitness are associated with daily functioning in patients with chronic fatigue syndrome ( CFS ) , this study addresses the correlations between exercise capacity and activity limitations /participation restrictions . Design : Prospect i ve observational study . Setting : An outpatient tertiary care , chronic fatigue clinic at the Vrije Universiteit Brussel ( VUB ) , Belgium . Subjects : Seventy-seven patients fulfilling the 1994 Centers for Disease Control and Prevention ( CDC ) case definition for CFS . Interventions : All patients filled in the Chronic Fatigue Syndrome Activities and Participation Question naire ( CFS-APQ ) and performed a maximal exercise stress test on a bicycle ergometer . Heart rate was monitored continuously by use of an electrocardiograph .  Metabolic and ventilatory parameters were measured through spirometry .  Results : A statistically significant correlation between the score obtained with the CFS-APQ and the body weight-adjusted peak oxygen uptake ( Spearman rho = -0.32 ; p = 0.005 ) , functional aerobic impairment ( rho = 0.33 ; p = 0.004 ) , workload/body weight ( rho = -0.30 ; p = 0.009 ) , exercise duration ( rho = -0.30 ; p = 0.008 ) , and the percentage of target heart rate achieved ( rho = -0.33 ; p = 0.004 ) was observed . The correlations between the remaining exercise capacity parameters and the scores obtained with the CFS-APQ all indicated a trend towards association ( 0.01<p<0.05 ) . Conclusions : These results suggest a moderate association between exercise capacity and activity limitations /participation restrictions in patients with CFS . The observed correlations lack strength to predict activity limitations / participation restriction based on exercise capacity parameters . Disability evaluation in CFS should therefore encompass both exercise capacity testing and measurements at the activity/participation dimension Objective : It was hypothesized that the use of exercise limits prevents symptom increases and worsening of their health status following a walking exercise in people with chronic fatigue syndrome . Design : An uncontrolled clinical trial ( semi-experimental design ) . Setting : Outpatient clinic of a university department . Subjects : Twenty-four patients with chronic fatigue syndrome . Interventions : Subjects undertook a walking test with the two concurrent exercise limits . Each subject walked at an intensity where the maximum heart rate was determined by heart rate corresponding to the respiratory exchange ratio = 1.0 derived from a previous submaximal exercise test and for a duration calculated from how long each patient felt they were able to walk . Main outcome measures : The Short Form 36 Health Survey or SF-36 , the Chronic Fatigue Syndrome Symptom List , and the Chronic Fatigue Syndrome — Activities and Participation Question naire were filled in prior to , immediately after and 24 hours after exercise . Results : The fatigue increase observed immediately post-exercise ( P= 0.006 ) returned to pre-exercise levels 24 hours post-exercise . The increase in pain observed immediately post-exercise was retained at 24 hours post-exercise ( P=0.03 ) . Fourteen of the 24 subjects experienced a clinical ly meaningful change in bodily pain ( change of SF-36 bodily pain score ≥10 ) ; 6 indicated that the exercise bout had slightly worsened their health status , and 2 had a clinical ly meaningful decrease in vitality ( change of SF-36 vitality score ≥20 ) . There was no change in activity limitations /participation restrictions . Conclusion : It was shown that the use of exercise limits ( limiting both the intensity and duration of exercise ) prevents important health status changes following a walking exercise in people with chronic fatigue syndrome , but was unable to prevent short-term symptom increases BACKGROUND Chronic fatigue syndrome ( CFS ) is a condition that may be associated with substantial disability . The Medical Outcomes Study Short-Form General Health Survey ( SF-36 ) is an instrument that has been widely used in outpatient population s to determine functional status . Our objectives were to describe the usefulness of the SF-36 in CFS patients and to determine if subscale scores could distinguish patients with CFS from subjects with unexplained chronic fatigue ( CF ) , major depression ( MD ) , or acute infectious mononucleosis ( AIM ) , and from healthy control subjects ( HC ) . An additional goal was to ascertain if subscale scores correlated with the signs and symptoms of CFS or the presence of psychiatric disorders and fibromyalgia . DESIGN Prospect ively collected case series . SETTING Patients with CFS and CF were seen in a university-based referral clinic and had undergone a complete medical and psychiatric evaluation . Other study subjects were recruited from the community to participate in research studies . PARTICIPANTS The study included 185 patients with CFS , 246 with CF , 111 with AIM , and 25 with MD . There were 99 HC subjects . MEASURES The  SF-36 and a structured psychiatric interview  were used . The SF-36 contains 8 subscales : physical , emotional , social , and role functioning , body pain , mental health , vitality , and general health- and a structured psychiatric interview .  RESULTS Performance characteristics ( internal reliability coefficients , convergent validity ) of the SF-36 were excellent . A strikingly consistent pattern was found for the physical functioning , role functioning , social functioning , general health , and body pain subscales , with the lowest scores in CFS patients , intermediate scores in AIM patients , and the highest scores in the HC subjects . The CFS patients had significantly lower scores than patients with CF alone on the physical functioning ( P < or = 0.01 ) , role functioning ( P < or = 0.01 ) , and body pain ( P < or = 0.001 ) subscales . The emotional functioning and mental health scores were worst among those with MD . The presence of fibromyalgia , being unemployed , and increasing fatigue severity all were associated with additional functional limitations across multiple functional domains , with increasing fatigue appearing to have the greatest effect . CONCLUSIONS The SF-36 is useful in assessing functional status in patients with fatiguing illnesses . Patients with CFS and CF have marked impairment of their functional status . The severity and pattern of impairment as documented by the SF-36 distinguishes patients with CFS and CF from those with MD and AIM , and from HC , but does not discriminate between CF and CFS Chronic fatigue syndrome ( CFS ) produces physical and neurocognitive disability that significantly affects health-related quality of life ( HRQL ) .  Multidisciplinary treatment combining grade d exercise therapy ( GET ) cognitive behavioural therapy ( CBT ) and pharmacological treatment has shown only short-term improvements . To compare the effects on HRQL of ( 1 ) multidisciplinary treatment combining CBT , GET , and pharmacological treatment , and ( 2 ) usual treatment ( exercise counselling and pharmacological treatment ) at 12 months of follow-up . Prospect i ve , r and omized controlled trial with a follow-up of 12 months after the end of treatment . Patients consecutively diagnosed with CFS ( Fukuda criteria ) were r and omly assigned to intervention ( n = 60 ) or usual treatment ( n = 60 ) groups . HRQL was assessed at baseline and 12 months by the Medical Outcomes Study Short-Form question naire ( SF-36 ) . Secondary outcomes included functional capacity for activities of daily living measured by the Stanford Health Assessment Question naire ( HAQ ) and comorbidities . At baseline , the two groups were similar , except for lower SF-36 emotional role scores in the intervention group . At 12 months , the intervention did not improve HRQL scores , with worse SF-36 physical function and bodily pain scores in the intervention group . Multidisciplinary treatment was not superior to usual treatment at 12 months in terms of HRQL . The possible benefits of GET as part of multidisciplinary treatment for CFS should be assessed on an individual patient basis Background : It has been argued that perceived functional incapacity might be a primary characteristic of chronic fatigue syndrome ( CFS ) and could be explained by physical symptoms . If so , it could be expected to be closely associated with physical , but not psychological symptoms . The study tests this hypothesis . Sampling and Methods : The sample consisted of 73 patients , with a diagnosis of CFS according to the Oxford criteria , r and omly selected from clinics in the Departments of Immunology and Psychiatry at St. Bartholomew ’s Hospital , London . The degree of fatigue experienced by patients was assessed using the  Chalder Fatigue Question naire and a visual analogue scale . Self-rated instruments were used to measure physical and social functioning , quality of life , and physical and psychological symptoms . Results : Principal-component analysis of all scale scores revealed 2 distinct components , explaining 53 % of the total variance . One component was characterized by psychological symptoms and generic quality of life indicators , whilst the other component was made up of physical symptoms , social and physical functioning and indicators of fatigue . Conclusions : The findings suggest that perceived functional incapacity is a primary characteristic of CFS , which is manifested and /or explained by physical symptoms OBJECTIVE Changes in physical activity are thought to play an important role in maintaining symptoms in chronic fatigue syndrome ( CFS ) . The aim of this study was to describe intraindividual physical activity patterns in more detail and to identify pervasively passive patients . METHODS With help of a movement-sensing device , physical activity levels were registered continuously over a 12-day period in 277 CFS patients . Within this registration period , the 10 largest activity peaks were computed . The intensity and duration of these activity peaks and their subsequent rest periods were described and compared to those of 47 healthy controls . In addition , the patients ' 12 daily activity scores were used to identify patients who were characterised by low levels of physical activity throughout the registration period . RESULTS The CFS sample had less intense and shorter activity peaks , while the average rest periods that followed these peaks lasted longer . Approximately one-fourth of the CFS sample differed distinctly from the control group and was labelled as pervasively passive . CONCLUSION The measurements and classification of actual physical activity levels were found to reduce heterogeneity in the CFS population and therefore could provide the opportunity to optimise behavioural intervention protocol s for CFS The relationship of sleep complaints to mood , fatigue , disability , and lifestyle was examined in 69 chronic fatigue syndrome ( CFS ) patients without psychiatric disorder , 58 CFS patients with psychiatric disorder , 38 psychiatric out- patients with chronic depressive disorders , and 45 healthy controls . The groups were matched for age and gender . There were few differences between the prevalence or nature of sleep complaints of CFS patients with or without current DSM-IIIR depression , anxiety or somatization disorder . CFS patients reported significantly more naps and waking by pain , a similar prevalence of difficulties in maintaining sleep , and significantly less difficulty getting off to sleep compared to depressed patients . Sleep continuity complaints preceded fatigue in only 20 % of CFS patients , but there was a strong association between relapse and sleep disturbance . Certain types of sleep disorder were associated with increased disability or fatigue in CFS patients . Disrupted sleep appears to complicate the course of CFS . For the most part , sleep complaints are either attributable to the lifestyle of CFS patients or seem inherent to the underlying condition of CFS . They are generally unrelated to depression or anxiety in CFS The study aim ed to 1 ) examine the point prevalence of asynchronous breathing in chronic fatigue syndrome ( CFS ) patients ; 2 ) examine whether CFS patients with an asynchronous breathing pattern present with diminished lung function in comparison with CFS patients with a synchronous breathing pattern ; and 3 ) examine whether one session of breathing retraining in CFS patients with an asynchronous breathing pattern is able to improve lung function .  Twenty patients fulfilling the diagnostic criteria for CFS were recruited for participation in a pilot controlled clinical trial with repeated measures . Patients presenting with an asynchronous breathing pattern were given 20–30 minutes of breathing retraining .  Patients presenting with a synchronous breathing pattern entered the control group and received no intervention . Of the 20 enrolled patients with CFS , 15 presented with a synchronous breathing pattern and the remaining 5 patients ( 25 % ) with an asynchronous breathing pattern . Baseline comparison revealed no group differences in demographic features , symptom severity , respiratory muscle strength , or pulmonary function testing data ( spirometry ) . In comparison to no treatment , the session of breathing retraining result ed in an acute ( immediately postintervention ) decrease in respiratory rate ( p<0.001 ) and an increase in tidal volume ( p<0.001 ) . No other respiratory variables responded to the session of breathing retraining . In conclusion , the present study provides preliminary evidence supportive of an asynchronous breathing pattern in a subgroup of CFS patients , and breathing retraining might be useful for improving tidal volume and respiratory rate in CFS patients presenting with an asynchronous breathing motion OBJECTIVE In this r and omized noninferiority study , the effectiveness and efficiency of stepped care for chronic fatigue syndrome ( CFS ) was compared to care as usual . Stepped care was formed by guided self-instruction , followed by cognitive behavior therapy ( CBT ) if the patient desired it . Care as usual encompassed CBT after a waiting period . METHOD A total of 171 CFS patients were r and omly allocated to stepped care or care as usual . Patients in both conditions were assessed 3 times : at baseline , after guided self-instruction or the waiting period , and after CBT . The primary outcome variables were fatigue severity ( Checklist Individual Strength ) and disabilities ( Sickness Impact Profile and Medical Outcomes Survey Short Form-36 ) . RESULTS An intention to treat analysis showed that stepped care ( N = 84 ) for CFS is noninferior to care as usual ( N = 85 ) . Both conditions were equivalent in reducing fatigue severity , reducing disabilities , and increasing physical functioning . The treatment results of both conditions were in accordance with those of previous r and omized controlled trials testing the effectiveness of CBT  for CFS . The total therapist time needed to treat a patient was significantly less in the stepped care condition . CONCLUSIONS Stepped care is as effective as CBT and is more time efficient for the therapist OBJECTIVE To test the efficacy of a grade d aerobic exercise programme in the  chronic fatigue syndrome .  DESIGN R and omised controlled trial with control treatment crossover after the first follow up examination . SETTING Chronic fatigue clinic in a general hospital department of psychiatry . SUBJECTS 66 patients with the chronic fatigue syndrome who had neither a psychiatric disorder nor appreciable sleep disturbance . INTERVENTIONS R and om allocation to 12 weeks of either grade d aerobic exercise or flexibility exercises and relaxation therapy . Patients who completed the flexibility programme were invited to cross over to the exercise programme afterwards . MAIN OUTCOME MEASURE The self rated clinical global impression change score , " very much better " or " much better " being considered as clinical ly important . RESULTS Four patients receiving exercise and three receiving flexibility treatment dropped out before completion . 15 of 29 patients rated themselves as better after completing exercise treatment compared with eight of 30 patients who completed flexibility treatment . Analysis by intention to treat gave similar results ( 17/33 v 9/33 patients better ) . Fatigue , functional capacity , and fitness were significantly better after exercise than after flexibility treatment . 12 of 22 patients who crossed over to exercise after flexibility treatment rated themselves as better after completing exercise treatment 32 of 47 patients rated themselves as better three months after completing supervised exercise treatment 35 of 47 patients rated themselves as better one year after completing supervised exercise treatment . CONCLUSION These findings support the use of appropriately prescribed grade d aerobic exercise in the management of patients with the chronic fatigue syndrome BACKGROUND Cognitive behaviour therapy ( CBT ) for chronic fatigue syndrome ( CFS ) is an effective but intensive treatment , requiring trained therapists . A minimal intervention based on CBT for CFS , guided self-instruction , was shown to be an effective treatment when delivered in a tertiary treatment centre . Implementing this intervention in a community-based mental health centre ( MHC ) will increase the treatment capacity for CFS patients . This study evaluated the effectiveness of guided self-instruction for CFS implemented in an MHC , delivered by nurses . METHOD One hundred and twenty-three patients were r and omly assigned to either guided self-instruction ( n=62 ) or a waiting list ( n=61 ) . R and omization was computer generated , with allocation by numbered sealed envelopes . Group allocation was open to all those involved . Patients fulfilled US Centers for Disease Control and Prevention ( CDC ) criteria for CFS . Primary outcome variables were fatigue severity and physical and social functioning , measured with the Checklist Individual Strength ( CIS ) and the Medical Outcomes Survey Short Form-36 ( SF-36 ) respectively . RESULTS After 6 months , patients who followed guided self-instruction reported a significantly larger decrease in fatigue compared to the waiting list [ mean difference -8.1 , 95 % confidence interval ( CI ) -3.8 to -12.4 , controlled effect size 0.70 ] . There was no significant difference in physical and social functioning . However , post-hoc analyses showed a significant decrease in fatigue and physical disabilities following the intervention in a subgroup of patients with physical disabilities at baseline ( SF-36 physical functioning ⩽70 ) . CONCLUSIONS Implementation of guided self-instruction in a community-based MHC was partially successful . The minimal intervention can be effectively implemented for CFS patients with physical impairments OBJECTIVES To test the hypothesis that group cognitive behavioural therapy ( CBT ) will produce an effective and cost-effective management strategy for patients in primary care with chronic fatigue syndrome/myalgic encephalopathy ( CFS/ME ) . DESIGN A double-blind , r and omised controlled trial was adopted with three arms . Outcomes were assessed at baseline and 6 and 12 months after first assessment and results were analysed on an intention-to-treat basis . SETTING A health psychology department for the management of chronic illness in a general hospital in Bristol , UK . PARTICIPANTS Adults with a diagnosis of CFS/ME referred by their GP . INTERVENTIONS The three interventions were group CBT incorporating grade d activity scheduling , education and support group ( EAS ) and st and ard medical care ( SMC ) . OUTCOME MEASURES The primary outcome measure was the Short Form with 36 Items ( SF-36 ) physical and mental health summary scales . Other outcome measures included the Chalder fatigue scale , Hospital Anxiety and Depression Scale , General Health Question naire , physical function ( shuttles walked , walking speed and perceived fatigue ) , health utilities index and cognitive function ( mood , recall and reaction times ) . RESULTS A total of 153 patients were recruited to the trial and 52 were r and omised to receive CBT , 50 to EAS and 51 to SMC . Twelve patients failed to attend for the 12-month follow-up and 19 patients attended one follow-up , but not both . The sample was found to be representative of the patient group and the characteristics of the three groups were similar at baseline . Three outcome measures , SF-36 mental health score , Chalder fatigue scale and walking speed , showed statistically significant differences between the groups . Patients in the CBT group had significantly higher mental health scores [ difference + 4.35 , 95 % confidence interval ( CI ) + 0.72 to + 7.97 , p = 0.019 ] , less fatigue ( difference -2.61 , 95 % CI -4.92 to -0.30 , p = 0.027 ) and were able to walk faster ( difference + 2.83 shuttles , 95 % CI + 1.12 to + 5.53 , p = 0.0013 ) than patients in the SMC group . CBT patients also walked faster and were less fatigued than those r and omised to EAS ( walking speed : difference + 1.77 , 95 % CI + 0.025 to + 3.51 , p = 0.047 ; fatigue : difference -3.16 , 95 % CI -5.59 to -0.74 , p = 0.011 ) . Overall , no other statistically significant difference across the groups was found , although for many measures a trend towards an improved outcome with CBT was seen . Except for walking speed , which , on average , increased by + 0.87 shuttles ( 95 % CI + 0.09 to + 1.65 , p = 0.029 ) between the 6- and 12-month follow-ups , the scores were similar at 6 and 12 months . At baseline , 30 % of patients had an SF-36 physical score within the normal range and 52 % had an SF-36 mental health score in the normal range . At 12 months , the physical score was in the normal range for 46 % of the CBT group , 26 % of the EAS group and 44 % of SMC patients . For mental health score the percentages were CBT 74 % , EAS 67 % and SMC 70 % . Of the CBT group , 32 % showed at least a 15 % increase in physical function and 64 % achieved a similar improvement in their mental health . For the EAS and SMC groups , this improvement in physical and mental health was achieved for 40 and 60 % ( EAS ) and 49 and 53 % ( SMC ) , respectively . The cost-effectiveness of the intervention proved very difficult to assess and did not yield reliable conclusions . CONCLUSIONS Group CBT did not achieve the expected change in the primary outcome measure as a significant number did not achieve scores within the normal range post-intervention . The treatment did not return a significant number of subjects to within the normal range on this domain ; however , significant improvements were evident in some areas . Group CBT was effective in treating symptoms of fatigue , mood and physical fitness in CFS/ME . It was found to be as effective as trials using individual therapy in these domains . However , it did not bring about improvement in cognitive function or quality of life . There was also evidence of improvement in the EAS group , which indicates that there is limited value in the non-specific effects of therapy . Further research is needed to develop better outcome measures , assessment s of the broader costs of the illness and a clearer picture of the characteristics best fitted to this type of intervention OBJECTIVES To investigate aspects of the validity of the total scores of the Tampa Scale for Kinesiophobia ( TSK ) , Dutch Version , which was modified to make it an appropriate question naire for the assessment of kinesiophobia ( fear of movement ) in chronic fatigue syndrome ( CFS ) patients ( the Dutch TSK-CFS ) , and , using this assessment tool , to examine the associations between kinesiophobia , exercise capacity , and activity limitations and participation restrictions in patients with CFS . DESIGN Prospect i ve observational studies . SETTING An outpatient fatigue clinic . PARTICIPANTS In the first study , 40 patients fulfilling the 1994 US Centers for Disease Control and Prevention ( CDC ) criteria for CFS were enrolled . The sample of the second study consisted of 51 CDC-defined patients with CSF . INTERVENTIONS Not applicable . Main outcome measures Study 1 : Subjects completed a set of question naires ; the Utrechtse Coping List ( UCL ) , the Dutch TSK-CFS , and the Dutch Baecke Question naire of Habitual Physical Activity . Study 2 : All patients completed 2 question naires (  Chronic Fatigue Syndrome Activities and Participation Question naire [ CFS-APQ ] , Dutch TSK-CFS ) and performed a maximal exercise stress test on a bicycle ergometer . The heart rate was monitored continuously by use of an electrocardiograph .  Metabolic and ventilatory parameters were measured through spirometry . RESULTS Study 1 : The Cronbach alpha coefficient for the individual item scores on the TSK-CFS was .80 . The total scores on the Dutch TSK-CFS showed a statistically significant correlation with both the avoidance/abide subscale of the UCL ( Spearman rho=.35 , P=.029 ) and the total score of the Baecke Question naire ( rho=-.45 , P=.004 ) . Study 2 : The total scores on the Dutch TSK-CFS showed a statistically significant correlation with the total scores on the CFS-APQ ( rho=.39 , P=.004 ) . No statistically significant associations were observed between the exercise capacity parameters and the total scores on the Dutch TSK-CFS . CONCLUSIONS These results provide evidence for the internal consistency and the convergent and congruent validity of the scores obtained by use of the Dutch TSK-CFS . Kinesiophobia appears to be associated with activity limitations /participation restrictions but not with exercise capacity in patients with CFS
target: Limited evidence was found for the psychometric properties and clinical usability of these instruments .
  However , the CFS-activities and participation question naire ( APQ ) is a disease-specific instrument with moderate content and construct validity .
background: PURPOSE To summarize measurement instruments used to evaluate activity limitations and participation restrictions in patients with chronic fatigue syndrome ( CFS ) and review the psychometric properties of these instruments .
  Chronic fatigue syndrome causes activity limitations and participation restrictions in one or more areas of life .