Chronic fatigue syndrome and response to letter to the editor by Lucy V. Clark and Peter D. White: prevention of symptom exacerbations in chronic fatigue syndrome

We would like to thank Dr Clark and Professor White for their special interest in our integrated model for rehabilitation of those with chronic fatigue syndrome (CFS), as recently presented in this journal (1). We are pleased with their comments and with the opportunity provided by the journal to respond to their Letter to the Editor.Clark & White challenge that exercise therapy can worsen the health status of patients with CFS and, on the other hand, explain in detail how their approach to graded exercise therapy for CFS prevents worsening of symptoms. They state that “a level of activity that does not exacerbate symptoms is set as a baseline” and “a baseline is set to avoid exacerbations in symptoms and the ‘boom and bust’ pattern characteristic of some patients with CFS”. They even explain what to do “if CFS symptoms are exacerbated”. By doing so, they acknowledge the possibility that exercise therapy can very easily worsen the health status of patients with CFS. From the way they explain their current approach of graded exercise therapy (GET) in CFS, it appears that they are making great efforts to avoid exacerbations in their patients. Avoiding exacerbations in response to exercise therapy was the main message of our special report, as evidenced by the title. England is fortunate to have specialized centres for the treatment of CFS; however, this is not the case worldwide. Many clinicians are treating patients with CFS as part of a mixed caseload of patients. These clinicians often struggle with their early attempts to apply exercise programmes to people with CFS, and our integrated approach combining self-management with graded exercise was intended to provide such clinicians with both a theoretical and practical framework to overcome this issue.