Physical Therapist's Guide to
Chronic Fatigue Syndrome
Chronic fatigue syndrome (CFS) is a condition that affects approximately 1% of the population in the United States. Without treatment, CFS often leads to disability. With treatment, including physical therapy the condition can be managed well, leading to an improved quality of life.
What is Chronic Fatigue Syndrome?
Chronic fatigue syndrome is a condition categorized by generalized fatigue that persists for 6 months or longer, and is more intense than would be expected based on the effort a person regularly exerts. Although science has yet to yield a full understanding of the underlying cause(s) of CFS, many researchers suspect impairments of the aerobic energy, immune system, and gastrointestinal systems may be responsible for the functional impairment experienced in individuals with this condition.
How Does it Feel?
The best known symptom of CFS is “postexertional malaise,” which causes a person to feel profoundly tired even with usual daily activities or minor overexertions. In addition, people with CFS may feel generalized body pains, headaches, difficulty thinking (ie, "brain fog"), and sleep disturbances. CFS has been described by some as feeling like a flu that has persisted for a very long period of time. These symptoms may fluctuate over time.
Full recovery is uncommon in adults with CFS, although it may be more common in children with CFS. Current clinical management relates to addressing symptoms and compensating for functional deficits in order to improve daily functioning.
Signs and Symptoms
Research has identified several symptoms of CFS, including:
- Fatigue. One of the primary symptoms of CFS is fatigue that lasts 6 months or more.
- Generalized pain. There is a significant amount of overlap between diagnoses of CFS and fibromyalgia, and some studies have suggested that 50% to 80% of people diagnosed with CFS also qualify to have a diagnosis of fibromyalgia. In both conditions, widespread distributions of pain are often present.
- Frequent headaches. Many people with CFS complain about frequent or recurring headaches, which can lead to avoiding physical activity.
- Muscle weakness. Decreased physical activity can result in general muscle weakness.
- Cloudy thoughts and confusion. CFS may make it difficult to concentrate or "stay on task."
- Disturbed sleep. Despite generalized fatigue, those with CFS often have difficulty sleeping.
- Flu-like symptoms. People with CFS report flu-like symptoms, including sore throats, muscle aches, and generalized fatigue.
How Is It Diagnosed?
CFS is a diagnosis of exclusion, meaning that no other health problem may be responsible for the fatigue. Diagnosis of CFS is symptom-based; your physician or physical therapist will base the diagnosis on the symptoms you report. They may also conduct medical tests to rule out other medical conditions. Unfortunately, there are no diagnostic tests to confirm the presence of CFS.
Your physical therapist may be the first to recognize onset of CFS because of its effects on your physical function. Your physical therapist may ask you:
- When do you feel fatigued and how long have you been feeling fatigued? Do you experience any widespread pain or discomfort?
- Have you noticed any significant changes in your ability to perform physical tasks?
- Have you noticed any sleep disturbances?
- Have you noticed any recent changes in your ability to think clearly?
Cardiopulmonary exercise testing, including 2 tests arranged 24 hours apart, may be used to characterize the severity of your functional impairment. In addition, your physical therapist may ask you to fill out a questionnaire in order to better understand your physical state, and to screen for the presence of other conditions.
How Can a Physical Therapist Help?
Your physical therapist will work with you to develop a treatment plan to help ease your discomfort and improve your ability to perform daily activities.
Because fatigue, pain, and weakness are all associated with CFS, physical therapist treatment will likely focus on improving short-term endurance and strength. Your physical therapist may also check for other conditions, such as depression and may refer you to other specialists for comanagement of your symptoms.
Physical therapy treatments may include:
Education. Your physical therapist will teach you strategies to help conserve energy while performing your daily activities.
Movement and Strengthening Exercises. Moving and exercising can improve your short-term endurance and strength and reduce your pain. Your physical therapist will help you identify specific movements that will help reduce your specific symptoms.
Manual Therapy. Manual (hands-on) therapy may be applied to manipulate or mobilize the skin, bones, and soft tissues to help reduce pain and improve movement.
Can this Injury or Condition be Prevented?
Unfortunately, the actual mechanisms behind CFS are not completely understood. To date, there is no sure way to predict or prevent the onset of CFS. However, early detection of the signs and symptoms related to CFS may help in its management.
Upon diagnosis, your physical therapist will work with you to develop strategies to better understand and manage your signs or symptoms.
- As with many conditions, education is key. Understanding maintenance strategies, such as balancing periods of activity and rest, can help you live a functional life with CFS.
- Moderate, short-duration exercises may be performed without making your symptoms worse after your symptoms are well controlled with a pacing self-management program.
- Cognitive behavioral therapy and psychotherapy may also help in addressing possible associated disorders, such as anxiety and depression.
Real Life Experiences
Angela is a small-animal veterinarian whose job requires her to be on her feet for 10 hours straight to perform surgeries during her workday.
Over the past few months, Angela has been feeling extremely tired, even on the days when her workload is light. Fearing that she could have multiple sclerosis like her sister, Angela makes an appointment with her primary care physician. He, after a thorough examination, refers her to a neurologist.
Angela's neurologist orders multiple tests, all of which comes back negative. At that point, she is given the diagnosis of CFS. Her neurologist refers her to physical therapy.
During her examination, Angela states that her fatigue tends to come and go, but she remains profoundly fatigued at all times. Angela has to stay in bed all weekend to recover from even a normal work week. She feels better earlier in the week than later in the week, but her symptoms are getting worse over time. Angela also says that she feels ill when she is fatigued, and that she also has difficulty concentrating. Angela reports that she has missed the past 3 weeks of work, due to her problems. She also reports that she feels anxious about the recent diagnosis, and that everything she has read about CFS sounds negative.
Her physical therapist identifies weakness, range of motion limitations, and muscle pain. The first cardiopulmonary exercise test reveals no abnormalities. However, the maximum volume of oxygen her body can consume is decreased on the second test, even though the test is rated as a maximal test. Her measurements suggest moderate to severe cardiovascular and pulmonary impairment on the second day, which explains her fluctuating functional deficits. Angela also experiences increased “brain fog” and body aches on the day of the second cardiopulmonary exercise test.
Following her exam, her physical therapist talks to her about her condition, and develops a strategy for physical therapy that he feels is best for her, consisting of activities and short exercises that will gently increase her strength and endurance, and help ease her pain.
Despite the complexity of her condition, Angela does well with a personalized course of physical therapy. Following several months of skilled services, she reports a 50% reduction in symptoms with her daily activities. With her physical therapist's help, Angela now feels confident that she can manage her symptoms as she performs her daily activities.
This story highlights an individualized experience of CFS. Your case may be different. Your physical therapist will tailor a treatment program to your specific needs.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat CFS. However, when seeking a provider, you may want to consider:
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist who is well versed in the bio psychosocial model of care and understands the complexities of CFS.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with CFS.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible. Keeping a journal highlighting when you experience pain will help the physical therapist identify the best treatment approach.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of CFS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
ME/CFS: A Primer for Clinical Practitioners. Chicago, IL: International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis; 2014. Accessed September 1, 2014.
Van Cauwenbergh D, De Kooning M, Ickmans K, Nijs J. How to exercise people with chronic fatigue syndrome: evidence-based practice guidelines. Eur J Clin Invest. 2012;42(10):1136–1144. Article Summary on PubMed.
White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377(9768):823–836. Free Article.
Davenport TE, Stevens SR, VanNess MJ, Snell CR, Little T. Conceptual model for physical therapist management of chronic fatigue syndrome/myalgic encephalomyelitis. Phys Ther. 2010;90(4):602–614. Free Article.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Joseph Brence, PT, DPT. Reviewed by the editorial board.