Chronisch Vermoeidheidssyndroom: diagnose, behandeling en ...

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40 Chronic Fatigue Syndrome KCE reports 88 The search for moderators of effect size produced only non significant trends. For instance, the following moderators had no impact on effect size: • criteria used to diagnose CFS (Oxford or 1994 CDC-criteria), • restrictive inclusion of individuals diagnosed with CFS (fatigue that had lasted longer is not harder to treat), • type of control group (supervised stretching and client centred treatment versus no treatment or usual care), • inclusion of cognitive components in treatment of fatigue, • number of treatment hours, • number of sessions, • objective and subjective measures, • individual and group treatment (but only one study dealing with group treatment had been included 91 ) • length of follow-up (while slight trend in favour of longer follow-up) Cho, Hotopf, and Wessely (2005) 19 also used meta-analysis to examine the placebo effect in treatment of CFS and found that the placebo response in CFS treatment was low. The placebo response across studies was less than for some other medical disorders and was lower for psychological interventions than for drug treatment. In other words, little of the effect of CBT for chronic syndrome is due to placebo. The authors recommend more focus on the non-specific, contextual aspects of CFS treatment in order to increase the effect of an active treatment. The collaborative therapeutic relationship was suggested as a key factor in the management of the condition. • Cognitive behavioural therapy is effective in adults and has been shown to reduce symptoms, improve function and improve quality of life (Evidence quality 1A) whatever the number of hours, the number of sessions or the treatment format (individual or group); • Evidence available in children indicates that cognitive behavioural therapy is effective in improving fatigue and symptoms, physical function, severity of condition and school attendance (Evidence quality 1A). 2.5.3.2 Graded exercise therapy (GET) Graded exercise is a rehabilitative approach based on the principle that prolonged inactivity causes physical deconditioning of the muscles, heart and lungs, which then maintains the effects of CFS. Graded exercise programmes consist of structured supervised activities or exercises that are progressively increased by a therapist in order to improve a patient's physical condition. Five large RCTs 79,80,81,82,83 considering graded exercise therapy as potential treatment for CFS patients were included both in a Cochrane systematic review 105 and the CRD systematic review. 1 The following treatment comparisons were made; • Exercise therapy versus treatment as usual or relaxation (to listen to a relaxation tape and other relaxation techniques) + flexibility (selected stretching exercises but avoiding doing any extra physical activities; maximum 30 minutes daily, 5 days/week), • Exercise therapy versus pharmacotherapy (fluoxetine), • Exercise therapy alone versus exercise therapy + pharmacotherapy (fluoxetine), • Exercise therapy alone versus exercise therapy + patient education. The exercise therapy regime lasted 12 weeks in all five studies and all used aerobic graded exercise therapy but with mixed levels in terms of intensity, 40% VO 2 maximum to 70% VO 2 maximum, and between 3 to 5 sessions/week with target duration of 30 minutes per session.
KCE Reports 88 Chronic Fatigue Syndrome 41 Contact with the therapist was minimal, usually once a week and most of the studies used exercise logs to measure adherence to treatment. The control interventions used were treatment as usual, relaxation/ flexibility, pharmacotherapy and patient education. All RCTs found significant improvements in the intervention group compared to the control groups. Fatigue, as measured by the Chalder fatigue scale, was improved at three months by exercise therapy when compared to the control group (relaxation/ flexibility or treatment as usual). 79 Measures of health-related quality of life and functional work capacity showed benefit of graded exercise over control. Giving the antidepressant fluoxetine alone is less effective than graded exercise to reduce fatigue. Combining the two interventions, exercise and fluoxetine, significantly reduced fatigue at 26 weeks compared with general advice with or without fluoxetine (Chalder fatigue score< 4:12/67 [18%] with GET v 4/69 [6%] with general advice; RR 3.10, 95% CI 1.05 to 9.10; NNT 9, 95% CI 5 to 91). Further studies are needed to examine this. An intensive patient educational intervention added to exercise therapy delivered no added benefit when compared to exercise therapy with usual explanation. This has an implication for the feasibility of the intervention, as it does not require large amounts of professional time in order to be effective. Edmonds 105 concluded that some patients may benefit from exercise therapy. Moreover, there is no evidence that exercise therapy may worsen outcomes. Authors underline that this treatment may be less acceptable to patients than other management approaches, such as rest or pacing. METHODOLOGICAL ISSUES AND CLINICAL IMPLICATIONS As for CBT, most studies on GET do not include an objective measure of activity and it is therefore unclear if any of the improvements can be attributed to the exercise regime. The often cited study on GET by Fulcher & White (1997) 79 revealed a significant reduction in mean levels of fatigue and an increase in physical functioning, but none of these measures had returned to normal and there were no improvements for anxiety, depression and quality of sleep. Moreover, there were no data showing that people had increased their activity levels after treatment. In another British study, Wearden et al. (1998) 80 showed a reduction in fatigue and improvement in functional work capacity in patients who completed the programme. However, 37% of the patients dropped out, and again, there was no information on post-trial activity levels. Moreover, studies on GET conducted in clinical settings have reported less impressive outcomes than the published randomised controlled trials, highlighting the need to evaluate all interventions in routine practice, as well as research clinics (e.g. Quarmby et al. (2007) 102 ). Five trials investigating incremental physical exercise programmes showed improvements in adults in various health outcomes including mental and physical fatigue, global improvement, disability, sleep, mood and cognition (Evidence quality 1A)
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