Graded exercise and cognitive behaviour therapy (CBT)

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If I have a patient, or even a physician, who tells me that they got better just with a graded exercise programme, then my reaction is that they could not have had CFS in the first place. Graded exercise on its own invariably makes CFS worse. Don't do it.

However, there comes a time in everyone's recovery when it is appropriate to increase one's daily activity. CFSs rightly become fearful of increasing activity because experience tells them that they will relapse. CBT is about addressing these fears and organising an activity programme that is so gentle that should one overdo things, any relapse will be very mild.

Firstly look at Pattern of recovery.

The first step in graded exercise is to reduce the amount of physical and mental work each day until all days are about the same i.e. first get out of the 'boom and bust' (doing too much one day, then paying for it for 2-3 days, then doing too much, etc.) cycle.

The next step is to feel well! Again see Pattern of recovery.

Finally increase the level of activity very slowly each day on the proviso that you continue to feel well. The key here is to vary activity. Different parts of the brain and body have to be exercised. One of the most active areas of the cortex is that which is concerned with vision. Processing information from a television for example requires much more activity than, say, listening to music. Television needs to be rationed. If the brain is working, it will consume 20% of body oxygen supplies (when it weighs 2% of the total body weight!). Similarly physical exercise should be done using as many different muscle groups and initially should be limited to simple stretching exercises without weights.

It may well take several months before significant changes are seen. There are inevitably 'wobbles' when you get a virus, or when life throws another crisis at you (life is all about going from one crisis to the next!). To adjust the level of activity to what is appropriate you have to judge things by the next day. If you are 'hungover' the next day then you have overdone it. There is a very fine 'window' between too much and too little.

You will have to spend some time each day, planning the day. This is tedious when the energy could be better spent doing something else. But if activities are not carefully controlled by the clock you will overdo things and have to start again.

Once you get going, you may find you are worse if you do too little! And this is a good sign because your body has adjusted to a new higher level of activity.

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