Effects of a short-term aquatic exercise intervention on symptoms and exercise capacity in individuals with CFS/ME, 2018, Broadbent et al

[alex3619]

Sci-hub link here.
Didn't read it yet, but this is what it says about recruiting of participants:

'We recruited patients who had a diagnosis of CFS/ME from their medical practitioner,
according to the updated International Consensus Criteria (Carruthers et al. 2011)
or the 1994 Centres for Disease Control criteria (Fukuda et al. 1994).'
[bolding mine]

I struggle with taking a shower... in no way I could have attended 20 min. of aquatic exercises...

Any severe patient with their typical symptoms would find just getting to aquatic exercise an unwinnable marathon. Maybe if they were brought there in a wheelchair ...?

Fukuda (bad) or ICC (good)? OR ... ?

 

[alex3619]

[My bold]

Does this mean some participants might not have been diagnosed with ME/CFS? If so, what are the implications?

It is not clear that more than a small subset with mono or post viral fatigue have ME. From what we know this is likely to be 10% or less.

 

[alex3619]

An increase in heart rate after training sounds positively pathological.

It sounds to me like patients are pushing themselves harder, and with ME that is probably not sustainable.

 

[Milo]

Any severe patient with their typical symptoms would find just getting to aquatic exercise an unwinnable marathon. Maybe if they were brought there in a wheelchair ...?

Fukuda (bad) or ICC (good)? OR ... ?

It’s not only going to and coming from. It’s changing into a bathing suit (from girl perspective, it can be hard) it’s facing the noise and smell of chlorine. Walking to and from the change room and the pool, to and from car and the center, and then to and from car and home. In my view like it was previously suggested, the people who submitted to the effort must have reduced the amount of activities they usually did.

 

[Jonathan Edwards]

It sounds to me like patients are pushing themselves harder, and with ME that is probably not sustainable.

I agree but if the increased heart rate is a sign of pushing harder it is not a sign of any cardiovascular improvement. I find it hard to know what to think but the way the abstract reads it looks as if the authors do not understand basic training physiology - yet they are sports medicine people?

And I think it said the heart rates were also higher pre-exercise - which has to be a bad sign. This could almost be objective evidence of exercise therapy causing harm if it wasn't likely to be completely meaningless.

 

[Barry]

It’s not only going to and coming from. It’s changing into a bathing suit (from girl perspective, it can be hard) it’s facing the noise and smell of chlorine. Walking to and from the change room and the pool, to and from car and the center, and then to and from car and home. In my view like it was previously suggested, the people who submitted to the effort must have reduced the amount of activities they usually did.

And presumably there can be cognitive overload issues too, which all drain energy.

 

[chrisb]

I thought the Ean Proctor case sufficient to disprove any general benefit from short-term aquatic exercise intervention.

 

[Trish]

I thought the Ean Proctor case sufficient to disprove any general benefit from short-term aquatic exercise intervention.

Throwing someone with very severe ME into a swimming pool and leaving them to sink or swim reminds me more of the ducking stool used to test if someone is a witch - if they drown they were innocent.

That is very different from modern hydrotherapy or pool based fitness regimes. I imagine there could be a case for hydrotherapy with people with ME who are immobile, so long as it is done using hoists, and lots of support and is designed purely to enable water supported passive joint mobilisation and very gentle movement.

I can't see any case for using it to try to increase activity or fitness - it is then just another form of GET, and likely to be harmful.

 

[Dolphin]

The remaining 4 weeks of the intervention consisted of twice-weekly aquatic sessions with 48–72 h recovery between sessions.

I suspect that generally exercise programmes for people with ME/CFS may be safer if there are 48+-hour gaps between exercise sessions. This allows one to have a better idea whether one has fully recovered from the previous session.

The PACE Trial-type exercise programmes encourage exercise 5-6 days a week
e.g.
(Extracts from the PACE Trial GET therapist manual)

However, if the participant is physically very disabled, fearful of exercise, or has an extremely low exercise tolerance, it may be more appropriate to begin with two weeks of stretching alone with no prescribed aerobic activity. ‘Stretch days’ can then be alternated with ‘aerobic days’ to start with. This will inevitably lead to fewer aerobic sessions than is desirable, and so should be discouraged as soon as possible in order to increase to five or six aerobic sessions per week.

This baseline should be a level of exercise that is achievable on a regular basis (5 or 6 days per week)

 

[Sean]

five or six aerobic sessions per week.

These people live in another universe.

 

[Dolphin]

Participants were instructed in the use of HR monitors (Polar T31, Oulu Finland) and the 0–10 RPE scale, and were asked to keep their exertion levels below 6/10 or “moderately hard”.

 

[Dolphin]

All exercises were self-paced.

 

[Dolphin]

Simple floating was also used as a relaxation exercise or a “time out” if the participant felt tired.

 

[Dolphin]

Pre-intervention (n = 11) Post-intervention (n = 11)
6 MWT HR @ 2 min (bpm) 91.8 ± 13.2 97.4 ± 10.1
HR @ 4 min (bpm) 94.6 ± 10.7 100.1 ± 8.6
6 MWT HR @ 6 min (bpm) 90.8 ± 10.6 100.3 ± 9.1

This makes me wonder whether the participants could have been exercising harder for the six minute walking test postintervention. In which case an increase in six minute walking test distance would be less interesting.

Saying this, the RPE [rating of perceived exertion] scores were lower in the postintervention group at each time point: one of these was significantly lower and another one was borderline (p= 0.057). However, these are self-reported measures, so might not be comparing like with like/could be biased.

O2sat are also given at two, four and six minutes. I'm not sure whether they give any information on how hard people are pushing themselves.

The baseline six minute walking test distance was 338.4 ± 39.1
the postintervention distance was: 399.2 ± 58.1

Healthy women of working age would generally score 500+.

 

[Dolphin]

This contrasts with the protocol in the PACE Trial where what participants are asked to do is determined by “their planned physical activity, and not their symptoms” (p.20); similarly, “a central concept of GET is to MAINTAIN exercise as much as possible during a CFS/ME setback” (p.51) and “if the participant reports an increase in fatigue as a response to a new level of exercise, they should be encouraged to remain at the same level for an extra week or more” (p.66). Bavinton J, Darbishire L, White PD - on behalf of the PACE trial management group. Graded Exercise Therapy for CFS/ME (Therapist manual)

The PACE Trial approach is about breaking the link between symptoms and how much activity is done. It is philosophically quite different.

From the current paper:

Several participants had days where they felt their symptoms were worse or they had other commitments, so did not attend the exercise session.

So this wouldn't be allowed with some exercise programmes.

Though with GET, you are allowed skip exercise sessions if you have new infections. I know one person who did GET as an inpatient who goes for long walks but claims she constantly gets "throat infections" and so stops walking then. I suspect many of these are simply ME flareups.

 

[Dolphin]

This pre- and post-intervention pilot study investigated the effects of 5 weeks of self-paced, low-intensity aquatic exercises on physiological outcome measures and symptoms in women with CFS/ME.

 

[Dolphin]

It is important to note that despite the improvements in the FACIT and tiredness scores, participant still considered themselves fatigued at the end of the study; the FACIT scores show a reduction in fatigue post-intervention but not the disappearance of this symptom.

 

[Dolphin]

Limitations of the study

This pilot study had a small sample size and whilst we reported many positive results, we are cautious about extrapolating our findings to the larger CFS/ME community. The small number of participants reflects the difficulty of recruiting CFS/ME patients in a rural area where distance and travel were barriers to participation. The lack of randomisation and a control group were also weaknesses of the study, again associated with the difficulty of recruiting large numbers of participants. However, there is support for our findings from other studies with similar cohort sizes, utilising similar aquatic programmes (Jentoft et al. 2001; Gusi et al. 2006; Mannerkorpi et al. 2009; Kieffer et al. 2012; Salem et al. 2011). More robust, randomised controlled studies are warranted.

 

[Dolphin]

Conclusion

In summary, the 5-week aquatic exercise intervention provided symptomatic and physiological benefits that increased participant exercise capacity. Further studies are needed to provide evidence for optimal frequency, duration and intensity of aquatic exercise sessions, and if there are longer-term benefits such as behaviour change and sustained reduction in symptoms. This mode of self-paced exercise may potentially benefit CFS/ME patients.

 

[Mij]

I have access to a heated pool in my building, its just a push of the elevator button and I'm there. The heat alone lowers my BP and my heart rate and pulse increases to compensate for this. I'm exhausted just trying to stay afloat.