chronic fatigue syndrome treatment chronic fatigue syndrome treatment treatment of chronic fatigue syndrome/myalgic encephalomyelitis (cfs/me) is variable and uncertain, and the condition is primarily managed rather than cured. only two treatments, cognitive behavioral therapy (cbt) and graded exercise therapy (get), have demonstrated reproducible evidence for their efficacy in people with cfs who are walking. 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 the evidence of effectiveness was inconclusive for most other interventions, with some reporting significant adverse effects. the wide variety of outcome measures used in cfs research was found to be a "fundamental problem" for assessing the effectiveness of interventions in general, and no intervention has proven to be effective in restoring the ability to work. there are no food and drug administration (fda) approved medications for me/cfs treatment, although medications are used without approval for the illness (off-label). drugs have been used in experimental studies of the illness that haven't been approved for market for any condition in the united states (for example, isoprinosine and rintatolimod). other proposed treatments include medical treatments and alternative medicine. rintatolimod has been approved for import and use in argentina. even when treated, the prognosis of cfs is often poor. recovery is "rare" even after a comprehensive rehabilitation programme. pacing pacing (activity management) is a management strategy rather than a therapy. pacing encourages behavioral change, but unlike cognitive behavioural therapy, acknowledge the typical patient fluctuations in symptom severity and experience delayed exercise recovery. pacing does not require patients to increase their activity levels unless they feel able to do so. 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. a small randomised controlled trial concluded pacing with get had statistically better results than relaxation/flexibility therapy. a 2008 patient survey by action for me found pacing to be the most helpful treatment and a 2009 survey of two norwegian patient organizations (me-association and menin) had found that 96% evaluated pacing as useful. in 2019, a large uk found that pacing led to greater improvements in patients' physical health, although a minority did report becoming worse. energy envelope theory energy envelope theory is a form of pacing that states patients should aim to stay within their 'envelope' of available energy, and by avoiding exceeding their energy levels the worsening of symptoms after mental and physical exertion (post-exertional malaise) should reduce, allowing for "modest" gains in functioning as a result. energy envelope theory is considered to be consistent with pacing, and is a management strategy suggested in the 2011 international consensus criteria for me, which refers to using an "energy bank budget". energy envelope theory was first described in 1999. several studies have found energy envelope theory to be a helpful management strategy for cfs, noting that it reduces symptoms and may increase functioning. energy envelope theory does not recommend unilaterally increasing or decreasing activity and is not intended as a therapy or cure for cfs. energy envelope theory has been promoted by various patient groups. pacing with a heart rate monitor some patient groups recommend pacing using a heart rate monitor to increase awareness of exertion, and to allow patients to stay within their aerobic threshold envelope. randomized controlled trials of pacing using a heart rate monitor are lacking. spoon theory spoon theory is a way of understanding activity management in chronic illness and is based on the idea that each patient has a limited number of "spoons", with each spoon representing their available energy. a healthy person has an unlimited amount of available energy each day, but a person with chronic illness has a limited amount and must choose which activities to do. spoon theory is commonly used by people with cfs. adaptive pacing therapy adaptive pacing therapy (apt) is a treatment target than a management strategy and should not be confused with pacing. apt states that a person with cfs should aim to gradually increase their level of activity over time, but must not exceed more than 70% of what they feel is their available energy. cognitive behavioral therapy according to the cognitive-behavioural model of cfs, it is the patient's interpretation of symptoms that primarily shapes their behaviour and perpetuates the illness, and that changing these can lead to complete recovery. cognitive behavioral therapy (cbt) based on this model attempts to reverse patients' symptoms by altering their interpretation of their symptoms and/or the behaviours they engage in as a result. cbt can be applied to cfs in other ways too. for example, it may be used help the patient cope with their disability by better management of rest and activity within the boundaries of the energy constraints of the disorder, and does not actively attempt to improve the patient's physical or psychological capacity. this type of intervention does not necessarily assume the symptoms originate from maladaptive illness beliefs. the cdc currently suggests supportive counseling may be helpful in coping with the impact of the illness, but does not directly suggest cbt. a 2011 systematic review of randomized controlled trial rcts found that cbt for cfs had moderate evidence of benefit for some patients, but that the effectiveness of cbt for cfs outside of specialist settings has been questioned and the quality of the evidence is low. however, in 2016 the full data for the larger trial involving cbt was released, which showed cbt did not result in any significant improvement in walking distance or employment. a 2002 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, and there were no conclusive improvements to physical functioning, depression, anxiety or psychological distress at either post treatment or later follow-up. data on adverse effects were not systematically presented by any included study. 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". for example, other therapies were used as attention placebo control groups, which limits confidence in the findings. 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. in 2015, an arhq review recommended the oxford criteria be retired due to the likelihood of wrongly classifying many patients with other conditions as having cfs. in 2016, an arhq addendum downgraded the evidence for cbt and stated it should not be used as a primary treatment. a 2010 meta-analysis of trials that objectively measured physical activity before and after cbt showed that although cbt effectively reduced patients' fatigue questionnaire scores, activity levels were not improved by cbt and changes in physical activity were not related to changes in fatigue questionnaire scores. they conclude that the effect of cbt on fatigue questionnaire scores is not mediated by a change in physical activity. according to the authors of a 2014 systematic review, the lack of changes to objectively measured physical activity contradict the cognitive behavioural model of cfs and suggest that patients still avoided postexertional symptom exacerbations and adapted to the illness rather than recovered from it. 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 have 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 many of their members which have indicated that cbt can sometimes make people worse, a common result across multiple patient surveys. one such survey conducted by action for me in 2001 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. a large survey commissioned in the uk by nice for the guidelines review found that cbt for cfs was not effective for more than half of people with cfs, and patients were more likely to get worse physically than to improve. group cbt group cbt is not recommended by the cdc or by the dutch health council. a systematic study conducted at the behest of the belgian government of over 800 cfs patients treated in four reference centers which tested cbt and get in a clinical setting concluded that although patient motivation for treatment seemed to be high and that in 71% the supervising team considered the patient to have reached their maximal capacity, "no patient had been cured. therapy provided systematically included cbt and get. after treatment duration of 41 to 62 hours of rehabilitation per patient of which 83% group based, spread over 6 to 12 months, patients' subjective feelings of fatigue were improved, but results concerning quality of life were equivocal. psychological problems or psychiatric co-morbidities improved, but still fell outside the range of healthy adults. physical capacity did not change; employment status decreased at the end of the therapy." the report noted that "it is difficult however, to judge these results, since no control group had been included." a 2002 cochrane systematic review updated on 2008 included four studies which used group cbt and concluded that it was less effective than individual cbt at reducing fatigue at post-treatment. a 2007 meta-analysis stated that the one included study which tested group cbt had produced a similar effect to the other studies using individual cbt. in a more recent study of a multidisciplinary intervention which combined group cbt and get with pharmacological treatment, at 12 months after completion this intervention was "slightly inferior" to usual care alone, resulting in no improvements to fatigue or health-related quality of life, and worse physical function and bodily pain scores. some cfs patients have comorbid depression and/or anxiety. children have been successfully treated using antidepressants and therapy. graded exercise therapy main article: graded exercise therapy a 2019 cochrane review found that people with cfs who performed exercises may feel less fatigued, there is positive effect of exercise on sleep, physical function and self perceived general health, although no outcomes were conclusive for pain, quality of life, depression. effects obtained with exercises were greater than pacing but similar to those obtained with cbt. a 2012 systematic review concluded that despite the consistent positive outcomes of exercise therapy studies for cfs, "exercise therapy is not a cure for cfs", and "full recovery from cfs is rare". a 2015 cochrane systematic review included five eligible studies on get and found statistically significant improvements to self-reported fatigue severity and physical functioning. this benefit was sustained after 6 months but became non-significant compared to the control group who did not receive get. functional work capacity was not significantly improved. get had a tendency towards higher dropout rates, and although there was no evidence that exercise therapy worsened outcomes on average, no data was reported for adverse effects. the authors state that the evidence base and the precision of the results are limited, and encourage higher quality studies "that involve different patient groups and settings, and that measure additional outcomes such as adverse effects, quality of life and cost effectiveness over longer periods of time". pragmatic rehabilitation pragmatic rehabilitation is "a programme of gradually increasing activity designed collaboratively by the patient and the therapist".