Psychology Textbook Chapter 18 Exercise and Chronic Fatigue

Chapter 18 Exercise and Chronic Fatigue James and Rosemary of Clinical , University of , Canada School of Medicine , University of , Canada Please cite as , 2021 ) Exercise and chronic fatigue . In Jones ( Essentials of exercise and sport psychology An open access textbook ( Society for Transparency , Openness , and Replication in Kinesiology . Attribution 40 International This content is open access and part of Essentials of Exercise and Sport Psychology An Open Access Textbook . All other content can be accessed at Chapter Overview Fatigue is a symptom that can be experienced by anyone , whether through extended physical or mental activity , sleep deprivation or other environmental and social factors . Typically , fatigue is temporary and can be alleviated by rest or sleep . However , for some people , fatigue is an symptom that causes considerable distress and negatively impacts quality of life . Fatigue that is pathological , persistent and not resolved by rest can be called chronic fatigue . One of the most striking things about chronic fatigue is that it is common in people with many different diseases and disorders . Even though the underlying causes of fatigue may be different from one disease to the next , there are remarkable similarities in the experience of chronic fatigue . One consequence is that treatments and therapies which reduce fatigue in people with one disease may also be effective in reducing fatigue in people with a completely different disease . Exercise is one such treatment . Perhaps because of the historical ( and incorrect ) view that fatigue is caused by the depletion of an unspecified physiological source of energy ( Hockey , 2013 ) exercise has long been examined as a possible treatment for chronic fatigue . Interestingly , there is growing evidence that exercise is an effective treatment to reduce chronic fatigue , at least in some cases . In this chapter , we will present the evidence for exercise as a treatment for chronic fatigue in four different patient groups people living with and beyond cancer , people with multiple sclerosis , people who have had a stroke , and people with myalgic fatigue syndrome . First , it is important to understand what is meant by the word fatigue , both in general and in relation to these clinical populations . For correspondence

Chapter 18 Exercise and Chronic Fatigue What is Fatigue ?

Fatigue is a word familiar to many people it can be used to describe how a person is feeling ( I really fatigued from my flight ) or describe an apparent alteration in someone behaviour , for example , a decline in an athlete performance ( they are fatigued and making lots of mistakes ) Somewhat surprisingly , despite the ubiquitous use of the word in everyday language , scientists have had a hard time describing what fatigue actually is . Fatigue has been described as either a feeling of tiredness , weariness or exhaustion , a measurable decrement in performance of an activity caused by the prior extended performance ofthe same activity , or an insufficiency of the muscles or central nervous system to maintain physical or mental performance ( Hockey , 2013 ) Fatigue is also often delineated by its proposed cause and consequence Fatigue has been described as either or , can be either central or peripheral , or can be acute or chronic . The term mental fatigue is typically used to describe feelings or behaviours which arise from the sustained performance of mentally demanding tasks , whilst is used to describe feelings and behaviours which arise from sustained performance in physically demanding tasks . Central fatigue can mean either mental fatigue or fatigue caused by , or which causes , a change in central nervous system function . Peripheral fatigue usually , but not always , refers to fatigue caused by or which causes changes in muscle function . Acute fatigue describes the temporary fatigue which arises from sustained task performance and which is alleviated by rest . Almost everyone experiences acute fatigue at one point in their lives , perhaps from studying hard for an exam or from a physically demanding hike . With all these different definitions and , you might have become fatigued ! Thankfully for us , and for the purposes of this book chapter , several attempts have recently been made to provide a unified description of fatigue that , as scientists , we can use to describe , study , and treat fatigue ( et , 2013 Penner Paul , 2017 ) Many diseases and disorders have their own definitions of chronic fatigue . We will present some of these for cancer , multiple sclerosis and stroke in sections of this chapter . However , as you will see , there are many common traits in each definition , supporting the proposal that a unified taxonomy can be used to describe fatigue ( et , 2013 ) Drawing together these definitions , we propose the following definition of chronic fatigue , which is applicable across a range of diseases A or perception of weariness , tiredness or exhaustion that is not alleviated by rest , is not proportional to activity levels and is a disabling negative symptom that interferes with daily activities and impairs quality of life . Importantly , the definition allows us to focus on fatigue as a symptom that is experienced across a range of diseases and disorders . This feeling or perception of fatigue may or may not be accompanied by a measurable decline in physical or mental function and performance , which has been referred to as performance fatigability ( et , 2013 ) Prioritizing the Patient Experience In exercise science , there is a tendency to focus on performance fatigability and use the term fatigue when referring to objective in performance . There is also a tendency to place more value on objective measurements ( such as a decrease in force during a motor task ) rather than subjective measures . Using the term fatigue in this way may originate from a focus on the sport or athletic performance . However , using fatigue to mean performance does not always reflect how the general public understands the term fatigue ( a feeling of weariness , tiredness or exhaustion ) In the case of clinically relevant chronic fatigue , the emphasis on objective ( or even actual ) fatigue makes little sense . There are many examples where a measure of ( such as a decline in muscle force during a sustained submaximal contraction ) is deemed to be a more important measure than a experience of fatigue . However , such objective measures are not inherently superior to a person experience , and this is particularly important to emphasize in relation to clinical populations 410

with chronic fatigue . A patient does not come to the clinic because they can no longer sustain a submaximal contraction of the forearm muscles . Patients come to the clinic because , for example , they are feeling overwhelming tiredness that is reducing their ability to go about their normal daily activities ( interacting with family and friends , concentrating on completing work tasks , the ability to walk to the shops without causing a huge energy crash ) and reducing their quality of life . In fact , most patients would only think something like sustained handgrip force was important if an exercise scientist told them it was . And what would happen if , for example , we improved the ability of the patient to sustain this handgrip force , perhaps by strengthening the forearm muscles used in the task ?

Would the chronic fatigue then be treated ?

Of course not . The patient experience , reported to the clinician or scientists , is what matters . outcomes are questionnaires that are used to get a rating of fatigue from the patient and often ask questions about fatigue severity or intensity , and interference with usual activities , and of fatigue ( physical , mental , emotional ) Some questionnaires are and have been carefully validated ( for example , based on clinical features of fatigue in a specific disease , qualitative interviews , and expert clinical consensus ) That is , they are highly relevant to the patient . In the sections below , we will be concentrating on the effect of exercise on fatigue measured as a outcome in several clinical populations . Photo by from Exercise and Fatigue Definition and Description More than of people will be diagnosed with cancer in their lifetime . Due to improvements in cancer prevention and treatment , more people are now living longer with and beyond cancer . Fatigue can be one of the principal concerns for people with cancer . The most widely accepted definition of fatigue ( is a distressing , persistent , subjective sense of physical , emotional , cognitive tiredness or exhaustion related to cancer or cancer treatment that is not 411

Chapter 18 Exercise and Chronic Fatigue proportional to recent activity and interferes with usual functioning ( Berger et , 2015 , 1014 ) It can be hard to understand if you have not personally experienced it , but compared with fatigue that can be experienced by healthy individuals , is more severe ( people with describe it as overwhelming and ) less likely to be relieved by rest , can limit daily activities , and can be debilitating ( Scott et , 2011 ) is a significant clinical problem that has historically been , especially in comparison to other common cancer symptoms such as pain or nausea . The experience of can be highly individual , but there are several common clinical features that have been identified . Alongside significant fatigue and an increased need to rest , these features can include limb heaviness or weakness , problems with memory , unrefreshing or sleep , a perceived need to struggle to overcome inactivity , and emotional reactivity ( Celia et , 1998 ) is assessed as a outcome , and for routine screening in clinical practice , individuals are asked to fatigue intensity over the past week on a scale of ( where no fatigue and 10 worst fatigue ) A score of 24 ( where none to mild , moderate , and severe ) helps identify fatigue as a problem and should be followed by a comprehensive fatigue assessment ( Howell et , 2013 ) fatigue is common during active treatment ( the period of weeks or months that a patient is receiving , for example , chemotherapy or radiation therapy ) and this can be true for treatment delivered with both curative and palliative intent . Estimates of the prevalence of vary due to differences in the methods used to measures and differences in the specific population being assessed ( considering there are many different cancer types and treatment protocols ) However , fatigue does tend to worsen with the progression of the disease and can be more severe with multimodality or treatment protocols . In the case of curative cancer treatment , fatigue resolves for most people in the weeks after the treatment has been delivered . However , for a of people , fatigue can become a chronic issue that can continue for years ( Jones et , 2016 ) This type of chronic ( also called ) can prevent people from returning to work and is associated with high levels of disability . Although the mechanisms leading to are not completely understood , it is well accepted that is multidimensional and is influenced by a range of factors , including underlying biological mechanisms ( Bower , 2014 ) Some of the factors that can contribute to are psychosocial , including depression , anxiety , and lack of social support . People with often report a lack of understanding from family , friends or doctors , and a lack of social and medical legitimacy for the symptom ( et , 2014 , can lead to social isolation and disengagement , loss of identity , and feelings of guilt and frustration about fatigue ( et , 2017 Penner et , 2020 ) can be difficult to articulate , and there are barriers that prevent people with from communicating with healthcare professionals about their fatigue , including not wanting to complain and a lack of awareness that there are effective treatments for fatigue ( et , 2002 ) is not trivial and more people now recognize the importance of the patient experience . Clearly , can have a significant impact on a person overall quality of life . The Role of Exercise in Treating Fatigue in People with Fatigue All people with cancer should avoid inactivity , be as physically active as current abilities and conditions allow , and return to daily activities as soon as possible following a cancer diagnosis ( et , 2018 ) However , for people with , exercise can be considered treatment . The mechanisms for the reductions of fatigue severity with exercise are not well understood but may include physiological factors such as increased cardiorespiratory fitness or reduced inflammation , and psychological factors , including reduced symptoms of depression , anxiety , and increased social support . Some of the evidence that supports exercise as a treatment for is based on systematic reviews and . A systematic review is a methodical search of the literature that aims to summarize the 412

current body of research . A is a statistical analysis that combines the results of multiple studies , often randomized controlled trials , and provides a high level of evidence on the effectiveness of an intervention . There are now several systematic reviews with on the topic of exercise for . In 2020 , van et al . concluded that the beneficial effects of exercise on fatigue in patients with cancer are consistent across demographic and clinical characteristics . In 2018 , et al . found that exercise has a large effect on in cancer survivors and that aerobic interventions with high adherence have the best result . In 2017 , et al . found that both exercise and psychological interventions are effective for reducing during and after cancer treatment , and they are significantly better than the available pharmaceutical options . In perhaps the most comprehensive review to date , et al . 2018 ) included 170 randomized controlled trials and found that physical activity significantly decreases the severity of fatigue in patients with cancer . Although there are many studies on exercise for , the body of research is not without limitations . In fact , in a systematic review of systematic reviews with , 2017 ) concluded that more randomized controlled trials are needed because the results on exercise for vary and are inconclusive . However , the researchers also noted that because exercise does not seem to make worse and is associated with numerous health benefits , exercise programs that take into consideration the unique needs of cancer patients can be recommended . Another limitation is that some populations are underrepresented as most research is conducted on people diagnosed with breast cancer , whereas other cancer types have been overlooked . Similarly , most research includes interventions that are delivered during chemotherapy or radiation therapy , but there are far fewer studies on exercise for people with chronic or for people with advanced cancer . Finally , the vast majority of studies do not specifically target participants with clinically relevant fatigue ( et , 2020 ) and this may contribute to the fact that although the beneficial effect of exercise of is consistently demonstrated , the size of the effect ( that is , the amount of improvement in fatigue ) is usually only small to moderate . In 2019 , a consensus statement from an international roundtable presented the most recent exercise guidelines for cancer survivors ( Campbell et , 2019 ) For some health outcomes , there was consensus that the evidence was enough to recommend an exercise prescription based on the principle ( Frequency , Intensity , Time and Type ) For , the recommendation is to exercise three times per week at a intensity for 30 min , either as aerobic exercise or aerobic exercise plus resistance training . The prescription provides a useful guideline , but exercise should be tailored to ensure the overall of the individual . There is no one size fits all exercise prescription for , and some people can exercise more frequently , for a longer duration or at higher than the recommendations made by Campbell et al . 2019 ) without adverse effects . In contrast , a subset of people with may experience a worsening of symptoms for multiple days after an exercise bout , and therefore , responses to exercise must be monitored carefully to avoid causing harm ( et , 2020 ) Finally , it can be counterintuitive or intimidating to become more physically active when you have , and so support for behaviour change must also be considered alongside any exercise prescription . Exercise and Fatigue in People with Multiple Sclerosis Definition and Description Multiple sclerosis ( is an disease , primarily affecting the brain and spinal cord . It is estimated that over million people worldwide have , and is a leading cause of adult disability ( Coles , 2008 ) The exact cause of is unknown but likely involves genetic and environmental factors . is characterized by the of axons in the central nervous system . 413

Chapter 18 Exercise and Chronic Fatigue It is believed that in people with , the immune system attacks myelin , the insulating sheath around axons that enables efficient action potential transmission in the central nervous system . Failures in cells have also been indicated as a possible mechanism of . The loss of myelin causes dysfunction throughout the central nervous system and can cause problems with ( including weakness ) sensory , autonomic and visual processes . The disease course of can be unpredictable , and the majority ( of people with have , meaning they experience periods with few or no symptoms ( remission ) which can be followed by periods where symptoms flare again ( relapse ) Eventually , becomes what is known as secondary progressive , where symptoms get progressively worse ( Coles , 2008 ) Between of all people with also report problems with fatigue , including adverse effects on activities of daily living , quality of life , and ability to work ( et , 1988 ) fatigue is defined as a subjective lack of physical mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities ( Multiple Sclerosis Council for Clinical Practice Guidelines , 1998 , For many people with , fatigue is the single most debilitating symptom they experience . Despite its prevalence and impact , the exact causes of fatigue in people with are unknown . Fatigue in people with can be thought of as either a primary or secondary symptom . Primary fatigue is assumed to be caused directly by the of the disease , such as inflammation , and . Secondary fatigue is thought to arise from associated psychological effects of , including sleep loss , depression , and pain . There are at present two primary suspected biological mechanisms for primary fatigue in immune and dysfunction and changes to brain activation . People with can have increased expression of , including and . Systemic of these has been linked to behaviours and symptoms , including increased fatigue . Alternatively , or even simultaneously , cortical , subcortical , and white matter lesions caused by successive and relatively unsuccessful seen in may also cause fatigue . The presence of these lesions may alter the structure and function of neural networks involved in cognition and sensorimotor planning and performance , causing increased feelings of effort and fatigue during physical and mental tasks . Secondary fatigue might be the consequence of other primary symptoms of People with often have problems sleeping and increased pain , and these symptoms are linked to the experience of fatigue ( Kos et , 2008 ) The Role of Exercise in Treating Fatigue in People with Multiple Sclerosis Despite being advised for many years not to exercise , exercise and physical therapy are now recommended treatments for people with . Some of the proposed benefits of exercise for people with include improvements in strength and cardiorespiratory fitness , improved balance , walking performance , and proprioception ( et , 2017 ) Exercise is also suggested to be an effective treatment in . In a 2015 systematic review and , et , 2015 ) reported a moderate effect of exercise on fatigue in people with . There were very few side effects of exercise reported , including very few relapses , suggesting that exercise can be safely used to treat fatigue in people with . Compared to usual treatment , endurance exercise , mixed exercise ( a mixture of strength and conditioning and endurance exercise ) and alternative forms of exercise such as yoga and tai chi were all shown to have a moderate beneficial effect on fatigue . However , as with cancer , the literature in support of exercise as a treatment for fatigue in people with has some limitations . In their systematic review , et , 2015 ) found significant heterogeneity in the literature . This means that there were many differences in methods , study populations , and outcomes between studies . This makes it harder for us to be able to say with certainty that exercise reduces fatigue . Much more research is required , with careful and large replication of previous effects needed for us to become more confident in these results . 414

It is perhaps unsurprising , given that the exact causes of fatigue are unknown , that we do not know exactly how exercise alleviates fatigue in people with . Nonetheless , several candidate mechanisms have been proposed , and these depend on whether it is primary or secondary fatigue . Exercise has been shown to have positive effects on cytokine expression and regulation , possible causes of primary fatigue in . Exercise has also been suggested to be and induce , meaning it has been shown to protect against brain damage and encourage beneficial changes to the brain , both of which may help alleviate primary fatigue . Proposed mechanisms for the effect of exercise on secondary fatigue include reductions in depression and increased socialization . Perhaps surprisingly , at present , it is not clear whether there is a direct link between physical and secondary fatigue . Nonetheless , it is possible that the effects of exercise on cardiorespiratory and muscular function may reduce secondary fatigue in people with ( et , 2017 ) There is some evidence that endurance and strength exercise may help alleviate both primary and secondary fatigue in people with , and exercise appears to be safe and does not cause a significant relapse . However , despite the growing body of evidence linking increased exercise participation and a range of symptom improvements in people with , including fatigue , participation levels remain low . It is estimated that perhaps as few as 20 of people with participate in physical activity and activity levels appear to decline as the disease progresses . Many factors may limit participation , from direct physical causes such as increased pain or reduced mobility , psychosocial factors including depression , and social support , and environmental factors such as limited access to suitable facilities ( et , 2017 ) At present , it is not clear what type of exercise and what dose of exercise is best to treat fatigue in people with More research is required on both the mechanisms of fatigue in people with and the pathways by which exercise may impact these mechanisms so that the promise of exercise as medicine for people with who report fatigue is realized . Exercise and Fatigue Definition and Description Stroke describes the brain damage caused by either a blockage or rupture of the blood vessels which carry oxygenated blood to the brain . It is estimated that over 30 million people worldwide have survived a stroke , and it is estimated that between 25 and 85 of these people experience fatigue ( can reduce the quality of life and negatively impacts activities of daily living for many months and years after stroke , even after successful rehabilitation of motor and cognitive function . The development of strategies and therapies to help reduce and manage fatigue is a priority for people who have had a stroke and has thus become a priority for researchers and ( et , 1999 ) Though multiple definitions for exist , Lynch and colleagues have described as a period of at least two weeks when an individual who has had a stroke experienced fatigue and a lack of energy , or an increased need to rest nearly every day or every day and this fatigue led to difficulty taking part in everyday activities ( Lynch et , 2007 ) The causes of are unclear . The majority of people who have had a stroke report feeling fatigued in the weeks afterwards and this is often referred to as early . However , not all of these people go on to experience chronic or late ' Indeed , a small number of people only experience fatigue some months after having a stroke . This suggests that chronic is not a direct consequence of injury to the brain but of the consequences of the stroke on brain structure and function . Whilst the location of the stroke might be related to early , it does not appear to relate to chronic . Several psychosocial and biological mechanisms of chronic have been proposed . A number of studies have shown that chronic is associated with depression 415

Chapter 18 Exercise and Chronic Fatigue ( et , 2006 et , 2005 ) There is some evidence that chronic may also be related to depression , though one must be cautious when interpreting these studies because there is a risk of recall bias . is also associated with a locus of control directed at more powerful others , such as , rather than a high internal locus of control . Possible biological mechanisms include increases markers , reduced drive , and physical impairment ( et , 2017 ) The Role of Exercise in Treating Fatigue Exercise has been proposed as a treatment for chronic . In their 2014 Physical Activity and Exercise Recommendations for Stroke and 2016 Guidelines for Adult Stroke Rehabilitation and Recovery , the American Stroke Association suggests that exercise may help alleviate ( et , 2014 et , 2016 ) Stroke patients often do not meet the recommended guidelines for daily activity , and up to 75 of people who have a stroke are characterized as sedentary . However , perhaps surprisingly , there is limited evidence that exercise alleviates . In a small pilot study , Clarke et al . 2012 ) suggested that a lifestyle education intervention , which included physical exercise education , was effective in reducing . Perhaps surprisingly , at the time of writing , the only direct evidence for the effects of exercise on has been provided from a single randomized controlled trial by and colleagues ( et , 2012 ) These authors reported that the addition of a graded exercise protocol to a intervention doubled the number of people who reported a clinically relevant reduction in compared to when just the cognitive intervention was applied . The exercise program was delivered so that it was tailored to the participants individual heart rates , and intensity was increased every two weeks . Although this small study provides some evidence of the effect of exercise on , it has yet to be replicated and does not provide any information about the mechanisms by which might be alleviated . Why , then , is exercise a recommended treatment for ?

One reason might be that exercise has many positive effects on people with stroke , and thus the prescription of exercise is recommended regardless of its effect on fatigue . However , much more research is needed about the effects of exercise after a stroke so that we can understand the types and volume of exercise required to provide meaningful help to patients in whom fatigue is a burden Photo by Alex Green from 416

Exercise and Myalgic Fatigue Syndrome Definition and Description Exercise has been described as medicine for more than 26 chronic diseases ( 2015 ) but can exercise really be considered medicine for everyone with a chronic illness ?

This section will explore how people with a condition called myalgic encephalomyelitis or chronic fatigue syndrome ( can be affected by even mild levels of exertion . is a complex , debilitating , and term illness characterized by chronic fatigue , a substantial reduction in the ability to do usual activities , and other symptoms such as cognitive dysfunction and sleep abnormalities . has been a topic of much debate and controversy , and historically , patients have felt marginalized and have had to struggle to have the legitimacy of recognized ( et , 2017 ) Many people with have not been diagnosed , partly due to the lack of laboratory or diagnostic tests and a lack of education for healthcare professionals about the condition . People with can struggle to keep a job , go to school participate in their family and social life . One of the main characteristics of is malaise , a worsening of symptoms after a physical or mental activity that would not have caused a problem before the illness ( Centers for Disease Control and Prevention , 2018 ) There has been difficulty in defining and measuring malaise ( Chu et , 2018 et , 2019 ) but it can involve exhaustion , cognitive difficulties , and pain that can peak between hours after the exertion ( Chu et , 2018 et , 2019 ) malaise can be unpredictable , disruptive to everyday life ( often requiring complete bed rest with little sensory input ) and can have a significant impact on emotional ( et , 2020 ) Considering this issue of malaise , it becomes easier to see that for a minority of people , a blanket recommendation for exercise has the potential to be harmful . Exercise Therapeutic for People with ?

The 2011 PACE trial , published in The Lancet ( a , prestigious medical journal ) involved a comparison of graded exercise therapy and cognitive behavioural therapy for people with ( see White et , 2011 , 2013 ) The investigators concluded both therapies were moderately effective for and led to recovery in over 20 of participants . However , there were several serious criticisms of the trial , including methodological concerns such as outcome switching . This means that during the trial , the researchers lowered their original threshold for recovery ( switched a study outcome ) resulting in more participants meeting the criteria for recovery . In general , improvements in measures were not reflected in markers of functional recovery ( the number of days lost from work ) Another area of controversy was that the interventions were based on a cognitive behavioural model of , which proposed that rather than ongoing disease processes , is maintained and perpetuated by dysfunctional and avoidance of activity ( see ( et , Patients with can benefit from psychological support to help cope with the condition but reject the implication that the disease can be reversed by overcoming illness beliefs ( Wilshire et , 2018 ) This model is disputed because it suggests that there is no ongoing biological basis for the disease , despite growing evidence to the contrary . Most patients do not think that graded exercise therapy is appropriate for their needs , and people with more severe report that exercise can have a negative impact ( et , Because the results of the PACE trial conflicted with a patient experience of managing their condition , and due to the previously mentioned methodological issues , the researchers were challenged to release the study data for reanalysis by independent scientists . Eventually , the controversy culminated in a UK court tribunal , where the researchers were ordered to share their data . A reanalysis of the data found that if the researchers had used their original criteria for recovery , only of patients who received graded exercise therapy would have met the threshold , compared to of patients who 417

Chapter 18 Exercise and Chronic Fatigue received standard medical care ( Wilshire et , 2018 ) This is an interesting case to consider because this published research not only distorted the scientific record ( indicated that graded exercise therapy was more beneficial than is likely the case ) but was so influential that it directly affected standard treatment recommendations for people with . Some organizations have now removed these recommendations from their guidance for people with , and an updated systematic review is underway due to the limited applicability of previous reviews ( et , 2019 ) Currently , increases in activity are only advised if patients feel they are coping with current activity levels ( Bested Marshall , 2015 ) Any program involving exercise must be tailored to the individual , with awareness and understanding that worsening of symptoms is possible , and symptoms must be monitored over several days ( not only immediately after exercise ) Future Directions Disease 2019 ( At the time of writing , more than one year since the first outbreak , the disease ( pandemic continues worldwide . This contagious and illness is caused by a novel named severe acute respiratory syndrome ( SARS ) To date ( February 2021 ) more than 100 million cases have been confirmed worldwide . Alongside fever , cough and shortness of breath , fatigue is one of the acute clinical features of infection . and researchers have focused on the acute phase of , but there is now a growing awareness that some patients experience an unexpectedly long and challenging recovery , with ongoing symptoms and complications that can last for months after infection . Researchers , patient groups and those affected by the condition are collectively calling this phenomenon long COVID ( Brown et , 2021 ) Long COVID does not seem to be an issue that is only affecting the minority of people who require hospitalization due to severe respiratory problems . Young and otherwise healthy people who had a mild presentation of symptoms can also experience prolonged symptoms . initiatives , such as the Research Team , were the first to conduct surveys to explore health problems after confirmed or suspected infection ( et , 2020 ) Fatigue , shortness of breath , brain and challenges are just some of the common symptoms , and many respondents who had been physically active before symptom onset had become largely sedentary . Furthermore , reports of fluctuating symptoms that can flair up unpredictably or in response to reveal the potential similarities between long COVID and ( et , 2021 ) The development of chronic fatigue has been observed in survivors of other epidemics ( Islam et , 2020 ) In earlier outbreaks , approximately of survivors of hospitalization or intensive care unit admission had fatigue , reduced quality of life , reduced exercise capacity , and psychological issues including stress disorder , depression and anxiety , even beyond six months after the illness ( Ahmed et , 2020 ) Although the impact of the infection is not yet well understood , similar findings are emerging ( et , 2021 ) Because 19 is a new disease and research is evolving rapidly , little is known about the mechanisms leading to lingering symptoms or what rehabilitation support is needed . As we have seen in this chapter , exercise can be therapy for conditions where chronic fatigue , inactivity , and mental health concerns are major problems . Looking to the future , helping people manage fatigue , gradually increase activity , regain lost quality of life and return to normal function should be a priority . Improvements in energy levels and breathlessness may be aided by careful tailoring , pacing , and modest goal setting ( et , 2020 ) There is a potential role for exercise scientists with knowledge of chronic fatigue , working alongside in the development of such exercise and rehabilitation recommendations for long haulers ( et , 2020 ) However , as we have seen in the case of , given the potential for malaise , a great deal of caution is required . Future research on responses to exertion and the efficacy of exercise as an intervention must be 418

transparently reported and with the patients ( and patient doctors et , 2020 ) who have survived not only a global pandemic but one of the major public health crises of our lifetimes . Conclusion Fatigue is a symptom common across several diseases and disorders . The etiology of fatigue likely differs between each disease , although often the precise causes are unknown . However , the experience and overall impact of chronic fatigue can be similar across different diseases and conditions . For several clinical populations , exercise is a recommended therapy to improve health and quality of life . There is also some evidence that exercise alleviates chronic fatigue in some diseases . Indeed , even when the evidence base is poor , such as in stroke , exercise may still be recommended due to numerous other benefits to physical and mental health . However , as we have also shown in the case of , extreme caution is required when recommending exercise to people with chronic fatigue . Without knowing the causes of the symptom , it is possible that a therapy that alleviates fatigue in one set of patients may worsen it in another . It is often said that exercise is medicine ( 2015 ) For this to be true , then much like a drug , it is vital that we understand the mechanisms of action and the dose of exercise that is safe and beneficial . With these in mind , in certain people , such as those who have been diagnosed with cancer or , exercise seems to be an effective and safe method to alleviate fatigue . In these people , a cautious prescription of exercise is likely warranted . Often , specific guidelines for the prescription of exercise in a clinical population have already been developed , and these can help the exercise scientist when designing and implementing an exercise program ( et , 2014 Campbell et , 2019 et , 2013 ) However , much more research is required before we can fully understand if , how , and why exercise can be used to treat chronic fatigue . Learning Exercises Read et al . 2013 ) Fatigue and fatigability in neurologic illnesses Proposal for a unified taxonomy ( in Further Reading ) Write down some examples ofthe type of statements you might hear from a client or patient when describing their fatigue . Think about whether they are describing their perceptions of fatigue or fatigability . Write down how you might explain to the patient why you need to measure both . Read Campbell et al . 2019 ) Exercise guidelines for cancer survivors Consensus statement from international roundtable ( in Further Reading , paying attention to the sections on fatigue ) Design a intervention for a person who has completed their cancer treatment six months ago but still reports feeling fatigued . Write down how you would explain the purpose of the exercise you have prescribed and some considerations for the exerciser , including possible side effects . We have provided four examples of clinical conditions where fatigue is a common symptom . Try searching for two more . Are there any existing recommendations for exercise for people with these conditions ?

If so , what are the proposed mechanisms by which exercise might help ?

419 Chapter 18 Exercise and Chronic Fatigue Further Reading , Arena , Eng , Franklin , Johnson , Mead , Roth , Tang , American Heart Association Stroke Council Council on Cardiovascular and Stroke Nursing Council on Lifestyle and Health Council on Epidemiology and Prevention Council on Clinical Cardiology . 2014 ) Physical activity and exercise recommendations for stroke survivors . Stroke , 45 ( Campbell , May , Schwartz , Matthews , Morris , Patel , Hue , 2019 ) Exercise guidelines for cancer survivors Consensus statement from international roundtable . Medicine and Science in Sports and Exercise , 51 ( 11 ) 2013 ) Fatigue and fatigability in neurologic illnesses Proposal for a unified taxonomy . Neurology , 80 ( Martin , Hicks , Wheeler , Smith , 2013 ) Development of physical activity guidelines for adults with multiple sclerosis . Archives Medicine and Rehabilitation , 94 ( Williams , Snow , Gavin , Scott , 2020 ) Characterization of Malaise in Patients With Myalgic Fatigue Syndrome . Frontiers in Neurology , References Ahmed , Patel , Greenwood , Eyre , Jones , 2020 ) clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome outbreaks after or ICU admission A systematic review and . Journal of Rehabilitation Medicine , 52 ( Blair , Boyle , Briggs , Burns , Campion , Cushing , Dixon , Dolman , Hammond , Judge , Woods , 2020 ) From doctors as patients A manifesto for tackling persisting symptoms of . 370 , Khan , Galea , 2017 ) Rehabilitation for people with multiple sclerosis An overview of systematic reviews . The Database Reviews , 2017 ( Baker , Ellis , Lewis , Norman , Roscoe , Sherwood , Turner , Walker , Phillip , 2020 ) The Stanford Hall consensus statement for rehabilitation . British Journal Medicine , 54 ( 16 ) Berger , Mooney , Carpenter , Cella , Loggers , Murphy , Pirl , National comprehensive cancer network . 2015 ) Fatigue , Version . Journal of the National Comprehensive Cancer Network , 13 ( 420

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