There is Level One evidence that patients with clinically-significant and medically-unexplained chronic fatigue states will benefit from a multi-disciplinary, cognitive-behavioural therapy (CBT) program incorporating graded exercise therapy (GET) and cognitive exercise therapy (CET). These chronic fatigue states include chronic fatigue syndrome (CFS), post-cancer fatigue (PCF), post-viral fatigue syndrome (PVFS) and post-infective fatigue syndrome (PIFS). This intervention is essentially a pragmatic therapy based on the chronic illness paradigm, in which a distinction is made between factors which may have precipitated the condition (i.e. infection or cancer therapy) and those which may act to perpetuate or exacerbate the ongoing illness (such as mood and sleep disorders, as well as loss of aerobic fitness).
In relation to CFS, well-controlled trials of CBT have found that more than 70% of patients who received 13–16 intervention sessions targeting these perpetuating factors improved in functional capacity, compared to approximately 20%–27% of participants assigned to relaxation or usual medical care. In addition, randomised controlled trials of activity pacing and GET in comparison with flexibility/relaxation interventions have reported significantly greater improvements in fatigue, functional status, and aerobic fitness. These improvements were sustained over 6–14 months of follow-up. The same interventions have been shown to be effective in randomised controlled trials for patients with PCF.
The CBT/GET/CET intervention has been implemented in the Australian clinical setting for patients with chronic fatigue states at the UNSW Fatigue Clinic. The Clinic provides a 18-week outpatient program designed as independent treatment modules that are combined by the clinicians (exercise physiologists and clinical psychologists) to form an integrated treatment approach, including four core modules:
- Education;
- Activity pacing and graded exercise therapy (GET);
- Interventions for sleep-wake cycle disturbance; and
- Interventions for neurocognitive disturbance (cognitive exercise therapy [CET]).
Additionally, there are three optional modules targeting:
- Depression
- Anxiety
- Coping
Each module includes validated self-report questionnaires and structured interview schedules for accurate assessment of the severity and functional impact of the illness dimension - firstly to guide the individualised treatment approach, and secondly to allow assessment of effectiveness of the treatment within each module, and the Program as a whole.
The UNSW Fatigue Clinic operates in a clinical academic framework at the University of New South Wales and so has (voluntary) research components aimed at assessing and improving effectiveness of the Program, as well as involvement in related studies seeking to better understanding the pathophysiology of medically-unexplained chronic fatigue states.
Referrals
Patients may be referred to the Clinic by their GP. The referral should:
- confirm the diagnosis of chronic fatigue syndrome (CFS), post-cancer fatigue (PCF), post-viral fatigue syndrome (PVFS), or post-infective fatigue syndrome (PIFS);
- include a brief description of key symptoms; and
- include results of the following laboratory tests – full blood count, markers of inflammation (ESR or CRP), kidney function tests, liver function tests, and thyroid function tests.
- The UNSW Fatigue Clinic provides a UNSW Fatigue Clinic GP Screening checklist to guide this process.
In addition, the following Care Plans are required:
- Mental Health Treatment Plan (MHTP) - must specify 6 clinical psychology consults and
- GP Management Plan (GPMP) & Team Care Arrangement (TCA) - must specify 5 sessions with the ‘exercise physiologist’.
Note that if the referral is for a patient who 16 years old or younger, we require a letter or report from their paediatrician (uploaded online, via the Program Application form).