Treatment of chronic fatigue syndrome (CFS) is variable and uncertain, and the condition is primarily managed rather than cured. Only two treatments, cognitive behavioral therapy and graded exercise therapy, have demonstrated reproducible evidence for their efficacy in ambulant (non-severely affected) patients. Other proposed treatments include medications, medical treatments, and complementary and alternative medicine.
Management techniques
CFS management techniques include behavioral interventions such as cognitive behavioral therapy (CBT, a form of psychological therapy), and graded exercise therapy (GET). Based on evidence from multiple randomized clinical trials (RCTs), a systematic review published in the Journal of the Royal Society of Medicine (October 2006) stated that CBT and GET interventions showed promising results, appearing to reduce symptoms and improve function. The review stated that evidence of effectiveness was inconclusive for most other interventions with some interventions reporting significant adverse effects. A systematic review published in 2004 concluded that depression was the only factor associated with unemployment, and that only cognitive behavior therapy, rehabilitation, and exercise therapy interventions were associated with restoring the ability to work, although for questions of disability and employment in CFS, the limitations inherent in the current literature are extensive.
Cognitive behavioral therapy
According to the cognitive-behavioural model of illness, the patient's interpretation of symptoms plays an important role in perpetuating the illness. CBT aims to help the patient change these negative beliefs with the goal being either to reduce the symptoms, help the patient cope with the illness, or to fully recover.
A systematic review of RCTs found that there is moderate evidence of benefit for CBT in CFS, but that the effectiveness of CBT for CFS outside of specialist settings has been questioned and the quality of the evidence is low. A 2008 Cochrane review of CBT concluded, " CBT is more effective than usual care for reducing fatigue symptoms in adults with CFS, with 40% of participants assigned to CBT showing clinical response at post-treatment, in comparison with 26% assigned to usual care control. ", however, it also stated that the benefits of CBT in sustaining clinical response at follow up are inconclusive. The review also concluded that while the quantity and quality of the evidence has grown in recent years "there is a surprising lack of high quality evidence on the effectiveness of CBT alone or in combination with other treatments to inform the development of clinical management programmes for people with CFS". One uncontrolled study with no follow-up found that CBT could facilitate full recovery in some patients, with 69% of the patient cohort no longer meeting the CDC criteria for CFS and "full recovery" occurring in 23% of CFS patients after CBT using the most comprehensive definition of recovery.
Another systematic review on CBT finds that "CBT was associated with a significant positive effect on fatigue, symptoms, physical functioning and school attendance." The reviewers state that the quality of many recent trials on CBT are lower quality randomized controlled trials or trials that did not involve random allocation. The reviewers also state that one recent, good quality trial of CBT in children and adolescence supports the effectiveness of CBT. The reviewers state that reasons for withdrawals typically remain unreported, and that a degree of publication bias seems to be present in CFS/ME literature as a whole. In one study, the effect of CBT has been demonstrated up to five years after therapy.
A 2007 meta-analysis found that the effectiveness of CBT depends on the diagnostic criteria used, with studies using the Oxford criteria having a trend towards significantly higher effect sizes that those using the CDC criteria. The review also notes that CBT for chronic fatigue disorders has about the same efficacy as diverse psychological treatments for a variety of psychological disorders.
According to a 2006 systematic review "very few studies have assessed the effectiveness of interventions for children and young people and for severely affected patients. The effectiveness of CBT for adolescents is supported by a recent high-quality RCT, although this had only 69 participants." Currently there is no research into the effectiveness of CBT for the severely affected, and these patients may be effectively excluded from trials due to the need to attend a clinic. Some CBT trials suffer from large dropout rates, up to 42% in one study, with a mean dropout rate of 16%. This compares to a 17% dropout rate in a trial of 432 patients receiving CBT for anxiety, "so is not unusually high" according to a 2007 meta-analysis.
CBT has been criticised by patients' organisations because of negative reports from some of their members , which have indicated that CBT can sometimes make people worse ; one such survey conducted by Action for ME found that out of the 285 participants who reported using CBT, 7% reported it to be helpful, 67% reported no change, and 26% reported that it made their condition worse"..
Related treatments
Many CFS patients face the stress of economic and legal problems. CFS sufferers may lose jobs, marriages, and the ability to work at all, causing severe financial loss and distress. A study which included 45 CFS patients found that psychodynamic counselling has comparable effectiveness to cognitive behavioral therapy (CBT) in the treatment of chronic fatigue.
Some CFS patients have comorbid depression and/or anxiety. Children have been successfully treated using antidepressants and therapy.
Graded exercise therapy
Two systematic reviews suggest that some patients may benefit from graded exercise therapy (GET), although there are some limitations with the evidence and the generalizability of the findings. The most recent of these reviews (published in 2006) also notes that "no severely affected patients were included in the studies of GET". Patient organisations' surveys commonly report adverse effects.
A New Zealand study suggests that GET may result in self-reported improvement in part by "reducing the degree to which patients focus on their symptoms."
Pacing
Pacing techniques encourage behavioral change while acknowledging patient fluctuations in symptom severity and delayed exercise recovery. Patients are advised to set manageable daily activity/exercise goals and balance their activity and rest to avoid possible over-doing which may worsen their symptoms. Those that are able to function within their individual limits may then start to gradually increase activity and exercise levels (GET) while maintaining pacing methods. The goal is to increase over time the level of routine functioning of the individual. A small randomised controlled trial concluded pacing with GET had statistically better results than relaxation/flexibility therapy.
Antiviral Treatments
In subsets of patients, various viruses have been reported as the causative agents of CFS, see Pathophysiology although so far consistent and compelling supportive evidence is still lacking. Others consider that treatment studies of subtypes may reduce the inconsistencies A number of antiviral treatments have been trialled with some benefit.
Ampligen
Nucleic acid (double-stranded RNA) compounds represent a potential new class of pharmaceutical products that are designed to act at the molecular level, it is an inducer of interferon and is considered in other ways to be antiviral and immunomodulatory .
One RCT evaluated Ampligen and found an overall beneficial effect.
In December 2009 the FDA refused to approve Ampligen for treatment of CFS. The FDA concluded that the two RCTs "did not provide credible evidence of efficacy."
Valacyclovir
Nucleosidic class drugs such as acyclovir, valacyclovir and ganicyclovir are inhibitors of viral replication during DNA (for DNA- and retroviruses) or RNA (for RNA viruses) multiplication.
A small RCT compared acyclovir against placebo and found that an equal proportion of patients recovered from placebo and with active treatment. The authors concluded that the improvement of patients reflected either spontaneous remission or the placebo effect. Three people withdrew from acyclovir treatment due to reversible renal failure.
Interferon
A systematic review has found two small RCTs to have evaluated interferon . One of the RCTs found an overall beneficial effect and the other showed some positive effects in relation to immunological outcomes only. The quality of both of these studies was considered poor. A 2007 review of research needs for CFS concluded that trials for interferon beta are now an important priority
IGG
A systematic review found five RCTs to have assessed the effects of immunoglobulin treatment for CFS ; of these, 2 RCTs showed an overall beneficial effect and the two RCTs showed some positive results, although in one of the studies this was for physiological effects only. The largest of the RCTs found no effect for the treatment. Another review concluded that "Given the weak evidence of benefit for immunotherapy, the potential harms indicate that it should not be offered as a treatment for CFS."
Pharmacological treatments
No pharmacological treatments have been establis
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