A Case Report

Do exercise programs developed using the results of exercise tests results really work in chronic fatigue syndrome? The folks at the Workwell Foundation use exercise tests to determine the heart rate at which your body begins to rely heavily on anaerobic energy production  – and spew out toxins known to cause pain and fatigue.

anaerobic energy production diagram

Reducing her levels of anaerobic energy production was the goal for this person with ME/CFS.

They believe that many people with ME/CFS increase their pain and fatigue levels unknowingly  by working at heart rates that keep them primarily using anaerobic energy.  Identifying the heart rate at which people with ME/CFS enter the ‘anaerobic zone’ should  allow them to slow down and thus have less pain, fatigue and cognitive problems, and feel healthier.

That’s the theory. Studies do show that people with chronic fatigue syndrome who regularly venture outside their ‘energy envelope’ have more pain and fatigue than those who don’t.

In this case Staci Stevens, the director at the Workwell Foundation,  reported  what happened symptomatically and physiologically, to one ME/CFS patient who followed a heart-rate based activity program tailored specifically for her, for a year.

Functional Outcomes of anaerobic rehabilitation in a patient with chronic fatigue syndrome: Case report with 1-year follow-up. Staci R. Stevens, MA, Todd E. Davenport, PT, DPT, OCS

The Patient….

was a 28 year old female diagnosed with ME/CFS and orthostatic intolerance. Fully ensconced in a push-crash pattern, she increased her activities when she felt better, then overdid it and crashed – waited until she felt better—and then did it all over again.  Over time she found she was crashing for longer and longer periods.  No longer employed, and finding that  even her household chores were becoming too difficult, she was clearly on a slippery slope downwards.

downhill sign

Patient ‘X’ was on a downhill slide prior to beginning Workwell’s heart rate based exercise and activity program

Cardiopulmonary tests indicated her peak volume of oxygen consumption was low normal (she probably would have crashed on a second day of exercise testing), and that her cardiorespiratory system failed to respond normally to exercise.

Specifically, her blood pressure, respiration, and ventilation (the amount of oxygen getting into her lungs) were all blunted during exercise. (This is called chronotropic incompetence and it’s often seen in ME/CFS.) Her blood pressure dropped when she stood (orthostatic intolerance) and failed to rise while she was on the stationary bike.

She felt well during and for six hours after the exercise test, and then started to relapse. She estimated it took her a month to recover.

Chronotropic Incompetence (CI)

The inability reach normal levels of heart rate, stroke volume, and oxygen loading during exercise may be common in ME/CFS and is common in some cardiovascular disorders. During maximal exercise your heart rate should double, your stroke volume (the amount of blood pumped out by the heart at a time) should be 30 percent higher, and you should have fifty percent more oxygen in your arteries as in your veins.

In healthy people CI is associated with increased risk of heart attack and mortality. We’ll have more on chronotropic incompetence in a future blog.

The Plan

Stevens entered the heart rate at which anaerobic energy production became dominant into patient ‘X”s heart monitor. Every time patient ‘X’ exceeded her target heart rate, a beep from her heart rate monitor (HRM) signaled her to sit or lie down.

Lying down was an essential part of  her exercise program. No longer did her body have to  devote energy to keep blood from pooling in her legs when she stood; when she exercised lying down it could devote all its energy to improving her fitness.

woman meditating

Breathing exercise to move the diaphragm and bring more oxygen to the tissues were included to reduce pain

Patient X was provided with flexibility, resistance, and short-term endurance exercises. Diaphragmatic breathing and gentle upper body stretches were included to reduce pain levels. The resistance exercises were done while lying down.

Stevens said the first thing she teaches every patient is to breathe from their diaphragm. Stating that the muscles around the ribs that move the lungs are among the most aerobic in the body, she noted that inhaling and exhaling slowly is an exercise used by people with pulmonary disorders. Yoga, meditation, and other disciplines focus on breathing, as well, to slowly to drop the heart rate, reduce stress, and reduce pain.

Results Suggest Healing 

After a year of heart rate monitor use, deep breathing, flexibility and short-term endurance exercises, how was patient X doing? She reported substantial improvements in general functioning and, importantly, some of her physiological measures notched upwards.

blood pressure monitor

Normal blood pressure increases during exercise suggested some healing had taken place.

Parts of her body began to respond more normally to exercise. Her respiratory rate (the number of breaths she took), the amount of oxygen she inhaled, and her blood pressure went up dramatically during exercise. At maximum effort during the first test her blood pressure peaked at a mere 112/72. After a year of doing ‘short-term’ endurance exercises below her targeted heart rate, her blood pressure was up to 170/98 and her respiratory rate had increased 42%.

Even though she was still limited aerobically, her heart rate and blood pressure were both increasing normally in response to exercise. It was as if her cardiovascular system had emerged from a state of partial hibernation.

Staci doesn’t have this kind of before/after data from many patients; they get disability, get the exercise program, and they’re gone. But this person came back. Staci was so amazed to see the degree of cardiovascular rehabilitation that had occurred that she asked her what medication she was taking. The answer was “none”… it was all due to the heart rate pacing and exercise program.

This time, instead of the maximal exercise test setting her back a month, it set her back a week.

Anaerobic Threshold Up, Aerobic Capacity Unchanged

Patient X’s  VO2 max, i.e., her ability to take and use oxygen to produce energy, stayed about the same, and that’s probably what we’d expect from a program focused on increasing anaerobic (not aerobic) functioning. .

Patient X’s anaerobic threshold–the heart rate at which she began producing more of her energy anaerobically–did change, however, and she was able to be active at a significantly higher level (about 20 heartbeats higher) without triggering a negative response.

image of improvement

Patient X wasn’t well but she had halted her decline and improved significantly during her year of heart rate monitor training

Staci Steven’s goal was to have Patient X stop triggering the inflammatory response people with ME/CFS experience with exertion. Staci felt that, by staying under her anaerobic threshold, patient X’s body was able to heal over time and respond to stress more normally. As long as she stayed within the aerobic ‘safety zone’ defined by her VO2 max test, she was more active and felt better as well.

This case report provides proof that keeping out of the push-crash cycle not only makes you feel better, it  can also physiologically help you to heal.

Workwell provides conditioning consultations and hope to have activity management programs up and running by next year.



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