PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
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FOR MEMBERS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION SEPTEMBER 2017 On the Menu: Nutrition-Related Physical Therapist Services NEXT 2017 Coverage PTs and Chronic Fatigue Syndrome
Bioness Spread
Vol 9 No 8 SEPTEMBER 2017
26 NUTRITION: A PORTION OF PTs’
DEPARTMENTS
MENU OF SERVICES
Diet and nutrition are key factors in managing many conditions 4 DID YOU KNOW?
that PTs treat. Here are some insights from clinicians who offer
nutrition-related services.
6 VIEWPOINTS
44 PROFESSIONAL
PULSE
16
+ Data Points
+ Health Care Headlines
+ Update On Opioids
+ Research Roundup
THE REAL STORY + Association Resources
ABOUT CHRONIC
56 MARKETPLACE
FATIGUE SYNDROME + Career Opportunities &
Research shows that the condition, Continuing Education
once ridiculed as imaginary, is a true
physiological disease. Here’s what
+ Products
to look for, and how PTs are helping
59 ADVERTISER INDEX
those who have it.
64 BY THE NUMBERS
32 NEXT 2017 COVERAGE
From physical therapy’s effects at the cellular level to inspiring stories
of resilience after the Boston Marathon bombing, the 2017 NEXT
Conference & Exposition brought it all. PT in Motion magazine’s
conference coverage recaps some of those events.
COLUMNS
8 COMPLIANCE
MATTERS
Here’s what PTs and PTAs
12 ETHICS IN
PRACTICE
A PT is asked to alter a
62 DEFINING
MOMENT
A veteran’s career path is
should know about local treatment schedule. Is more forged on the battlefield.
coverage determinations always better?
under Medicare.
2 PTinMOTIONmag.org / September 2017
Did You Know? APTA Board of Directors
The Medicare
OFFICERS
President American Physical
Sharon L. Dunn, PT, PhD Therapy Association
Vice President
Lisa K. Saladin, PT, PhD, FAPTA 1111 N Fairfax Street
Alexandria, VA 22314-1488
Therapy Cap
Secretary
Roger A. Herr, PT, MPA 703/684-2782 • 800/999-2782
Treasurer ptinmotionmag@apta.org
Jeanine M. Gunn, PT, DPT
Speaker of the House
Susan R. Griffin, PT, DPT, MS
January 1999
Vice Speaker of the House Magazine Staff
Stuart Platt, PT, MSPT Editor
DIRECTORS Donald E. Tepper
donaldtepper@apta.org
Susan A. Appling, PT, DPT, PhD
Associate Editor
Cynthia Armstrong, PT, DPT
When the initial $1,500 annual cap Anthony DiFilippo, PT, PDT, MEd
Eric Ries
ericries@apta.org
was imposed on physical therapy and Matthew R. Hyland, PT, PhD, MPA
Sheila K. Nicholson, PT, DPT, JD, MBA, MA
Contributing News Editor
Troy Elliott
speech-language pathology services Carolyn Oddo, PT, MS troyelliott@apta.org
Robert H. Rowe, PT, DPT, DMT, MHS
provided to Medicare patients. Kip Schick, PT, DPT, MBA
Association Staff
Publisher
3
Sue Whitney, PT, DPT, PhD, ATC, FAPTA Lois Douthitt
Vice President, Strategic
Editorial Advisory Group Communications and Alliances
Times the cap was delayed before Charles D. Ciccone, PT, PhD, FAPTA
Gordon Eiland, PT, MA, ATC
Jason Bellamy
Chief Executive Officer
going into effect January 1, 2006 Chris Hughes, PT, PhD Justin Moore, PT, DPT
Benjamin Kivlan, PT, MPT Advertising Manager
(other than a 3-month period in 2003 Peter Kovacek, PT, DPT, MSA
Julie Hilgenberg
juliehilgenberg@apta.org
when the moratorium expired before Robert Latz, PT, DPT
Design
Jeffrey E. Leatherman, PT
legislation reinstated it). Allison M. Lieberman, PT, MSPT TGD Communications
March 2006
creative@tgdcom.com
Kathleen Lieu, PT, DPT
Alan Chong W. Lee, PT, DPT, PhD Advertising Sales Office
Luke Markert, PTA Ad Marketing Group
2200 Wilson Boulevard, Suite 102-333
Daniel McGovern, PT, DPT, ATC
Arlington, VA 22201-3324
Nancy V. Paddison, PTA, BA
When the therapy cap exceptions Tannus Quatre, PT, MBA
PRODUCT DISPLAY ADVERTISING
Jane Dees Richardson, President
process began, enabling PTs to bill for Keiba Lynn Shaw, PT, MPT, EdD
703/243-9046, ext 102
Nancy Shipe, PT, DPT, MS jrichardson@admarketinggroup.com
services that exceeded the cap. Jerry A. Smith, PT, MBA, ATC/L
RECRUITMENT AND COURSE ADVERTISING
13
Mike Studer, PT, MHS
Meredith Turner
Sumesh Thomas, PT, DPT 703/339-6948
Mary Ann Wharton, PT, MS mturner@admarketinggroup.com
Times the exceptions process to the ©2017 by the American Physical Therapy Association (APTA). PT in Motion (ISSN 1949-3711) is
caps has been extended, including published monthly 11 times a year, with a combined December/January issue, by APTA, 1111 N
Fairfax St, Alexandria, VA. SUBSCRIPTIONS: Annual subscription, included in dues, is $10. Single
through 2017. copies $20 US/$25 outside the US. Individual nonmember subscription $114 US/$134 outside
the US ($194 airmail); institutional subscription $144 US/$164 outside the US ($224 airmail). No
$1,980
replacements after 3 months. Periodicals postage paid at Alexandria, VA, and additional mailing
offices. POSTMASTER: Please send changes of address to PT in Motion, APTA Member Services, 1111
N Fairfax St, Alexandria, VA 22314-1488; 703/684-2782. Available online in HTML and a pdf format
Therapy cap capable of being enlarged for the visually impaired. To request reprint permission or for general
inquiries contact: ptinmotionmag@apta.org.
threshold for 2017. Threshold for the
automatic exceptions process is $3,700. DISCLAIMER: The ideas and opinions expressed in PT
in Motion are those of the authors, and do not necessarily
reflect any position of the editors, editorial advisors, or the
American Physical Therapy Association (APTA). APTA
Source: History of Medicare Therapy Caps webpage.
prohibits preferential or adverse discrimination on the
American Physical Therapy Association. https://www. basis of race, creed, color, gender, age, national or ethnic
apta.org/FederalIssues/TherapyCap/History/. origin, sexual orientation, disability, or health status in all areas including, but not limited to, its
qualifications for membership, rights of members, policies, programs, activities, and employment
practices. APTA is committed to promoting cultural diversity throughout the profession.
ADVERTISING: Advertisements are accepted when they conform to the ethical standards of APTA.
PT in Motion does not verify the accuracy of claims made in advertisements, and publication of an
ad does not imply endorsement by the magazine or APTA. Acceptance of ads for professional devel-
opment courses addressing advanced-level competencies in clinical specialty areas does not imply
review or endorsement by the American Board of Physical Therapy Specialties. APTA shall have the
right to approve or deny all advertising prior to publication.
APTA is committed to being a good steward of the environment.
PT in Motion is printed using soy-based inks as defined by the
American Soybean Association, is packaged using recyclable
film, and uses Cadmus Communications, a Forestry Stewardship
Council-certified supplier that recycles unused inks into reusable
black ink, recycles all press plates into aluminum blocks, recycles
all manufacturing waste, and purchases ink from suppliers whose
manufacturing processes reduce harmful VOCs (volatile organic
compounds).
4 PTinMOTIONmag.org / September 2017
Viewpoints
PT in Motion welcomes your opinions. We will consider
letters, email, and posts that relate to specific articles in
the magazine and those of general interest to the physical
therapy profession.
Online Comments
In addition to writing to the editor, PT
in Motion readers share comments
online. Here’s a sampling of their First Choice for a Second Career
responses to stories in the July 2017 About PTAs who began their work lives in a different career but were drawn
issue of the magazine. to physical therapy
Shout out to the “seasoned” professionals like me! I’m soon to be 39, and
my son and I will graduate next spring. He will celebrate the end of high
school, and me the successful completion of a PTA program. It’s no joke
being an older student. I have to work super hard, but it is worth it. All that
problem solving keeps the mind sharp.
Keeping Pain Out of the Posted by Megan Fitzgerald
Red Zone
Thank you for an excellent article profiling my PTA peers! I also chose
About the latest thinking on the the field as a second career, returning to school at 43 after a knee injury
physical and psychological mecha- rehab experience and my youngest son’s entering high school. I love my
nisms of chronic pain rewarding career treating pediatric patients and their families, as well as
mentoring current and future PT and PTA students. I forwarded this article
to my new daughter-in-law (just married to that same youngest son!) as she
Recently my husband and I were is deciding between PT and PTA school when she completes her service as
having this very discussion: How an Army officer in 18 months.
could we determine if the (chronic)
pain a family member was report- Posted by Kathy Gamble
ing as “so bad, it’s never been this
bad” was true pain or not? This
article could not have come at a
better time. We will definitely read
it with great interest and in great Defining Moment: Amputation
detail.
and Ambulation
Posted by Celeste Dunlap
Member Toran MacLeod, PT, PhD, recounts his
decision to become a physical therapist.
How would you relate this research
to situations in which there actually
is ongoing tissue damage, such as I wish my brother had lived long enough to have
osteoarthritis and stenosis? your care. You are a great one, Toran.
Posted by Elizabeth Neilson Posted by Kay Ashbrook
MAIL PT IN MOTION EMAIL PTINMOTIONMAG@APTA.ORG In all correspondence, please include
1111 North Fairfax Street FACEBOOK WWW.FACEBOOK.COM/APTAFANS
your full name, city, and state.
Alexandria, Virginia 22314-1488 Letters and posts may be edited for clarity,
TWITTER @APTATWEETS
style, and space. Published letters and com-
ments do not necessarily reflect the positions
or opinions of PT in Motion or the American
Physical Therapy Association.
6 PTinMOTIONmag.org / September 2017
PTinMOTIONmag.org / September 2017 7
Compliance
Matters By Kyle Levin, JD
Local Coverage Determinations
Under Medicare
Here’s what PTs and PTAs should know about the process.
Many physical therapists (PTs) and records for selected claims,
and coordinating with CMS
physical therapist assistants (PTAs) and other contractors. In
know the names Noridian Healthcare this column, however, let’s
take a closer look at MACs’
Solutions, Novitas Solutions, and Cahaba role in making local cover-
Government Benefit Administrators. age determinations (LCDs).
They are 3 of the largest Medicare The ABCs of LCDs
Kyle Levin, JD, is a
Administrative Contractors, or MACs— Simply put, an LCD is a
regulatory affairs MAC’s decision to cover a
specialist at APTA.
private health insurers that have been particular service or not.
awarded contracts from the Centers for Section 1869(f)(2)(B) of the
Social Security Act states,
Medicare and Medicaid Services (CMS) “[T]he term ‘local coverage
to process claims for Medicare parts A determination’ means a
determination by a fiscal
and B services and for durable medical intermediary or a carrier
equipment (DME) for Medicare fee-for- under part A or part B,
as applicable, respecting
service beneficiaries. MACs are granted whether or not a particular
jurisdiction over defined service areas, item or service is covered
on an intermediary- or
with 12 MAC jurisdictions for Medicare carrier-wide basis under
parts A and B processing and 4 MAC such parts … .”1 The Act fur-
ther requires that the LCD
jurisdictions for DME. consider only “reasonable
In addition to processing in the Medicare program, and necessary” conditions
claims, MACs provide ser- handling redetermination of coverage.
vices that include making requests, educating provid-
While the statute gives
and accounting for pay- ers about billing require-
MACs significant latitude
ments, enrolling providers ments, reviewing medical
8 PTinMOTIONmag.org / September 2017in deciding whether to All new LCDs are subject advantage of the opportu-
cover a service, they do to a notice and comment nity to provide feedback on
not have carte blanche. If a period. A notice and com- the LCD is critical, as LCDs
national coverage determi- ment period also is required dramatically affect patients’
nation (NCD) is in place, for any adapted LCD that access to appropriate care
MACs cannot deny cover- is more restrictive than, or as well as reimbursement to
age of services contained substantially changed from, providers. While MACs are
within it. An NCD is a CMS its predecessor. During free to create their policies
determination of services the notice and comment within the boundaries of
that Medicare will cover period, the LCD is publicly existing NCDs, APTA has
nationally. If an NCD does displayed—typically both found that they will con-
not specifically mention in the Medicare coverage sider evidence-based argu-
coverage of a service, it is database of CMS’s website ments for specific changes
up to the MAC to deter- and on the website of that in an LCD. The association
mine whether to create an particular MAC. therefore embraces this
LCD to cover it. opportunity to submit
Each MAC has a carrier comments on LCDs that
Creation of an LCD occurs advisory committee com- affect the physical therapy
in stages and is governed by prising members of the community.
Chapter 13 of the Medicare medical community who
Program Integrity Manual. 2 advise the MAC on LCDs. After the 45-day public
If a MAC has created an The comment period begins comment period ends, the
LCD, other MACs may adopt once the document has been comment review period
it for their own jurisdictions. distributed to this commit- begins. During this time,
If no policy exists, or if an tee and to other members of the MAC’s medical director
existing policy cannot be the medical community. and staff review all received
adapted to the situation at comments, formulate
hand, MACs may draft their CMS mandates that the responses, and, as they deem
own LCDs based on their comment period be at least appropriate, make changes
review of the medical litera- 45 days, to allow enough to the LCD.
ture and their understanding time for members of the
of local practice. public to voice their opin- Next is the notice period.
ions about the LCD. Taking The finalized LCD is posted
PTinMOTIONmag.org / September 2017 9Compliance
Matters
Acronyms
CMS: Centers for Medicare and Medicaid Services
DME: Durable Medical Equipment
LCD: Local Coverage Determination
MAC: Medicare Administrative Contractor
NCD: National Coverage Determination
the MAC to revise the active know how to bring import-
LCD. The stakeholder details ant issues to the MAC’s
perceived deficiencies and attention.
proposes appropriate correc-
tions. The level of evidence To determine your MAC
to the MAC’s website and required for reconsideration jurisdiction, visit the CMS
the Medicare coverage is the same as that required website at www.cms.gov/
database. The LCD is not yet for creation of a new LCD. Medicare/Medicare-
active, however. Providers Contracting/Medicare-
have 45 days to familiarize The MAC then has 30 days Administrative-Contractors/
themselves with the LCD to rule on the request’s Who-are-the-MACs.
before it is implemented. If validity. If it’s deemed valid, html#MapsandLists.
the MAC or CMS does not the LCD is modified accord-
ingly, and an explanation of To consult the Medicare
extend the notice period, the
the changes is incorporated coverage database—where
LCD becomes active on the
into the LCD’s language. If, you can review draft,
46th day. It then remains
conversely, the request is active, and retired LCDs,
active until it is retired.
deemed invalid, the MAC as well as all NCDs—go to
Although the LCD is active, has 90 days to outline its www.cms.gov/medicare-
opportunities remain to rationale for the decision. coverage-database/
modify it should issues arise overview-and-quick-search.
aspx?list_type=ncd.
that were not foreseen prior Resources
to activation. In some cases,
Those are the basics of the REFERENCE
for example, the finalized
LCD excludes certain ser- LCD process. APTA seeks 1. Social Security Administration.
Compilation of the Social Security
vices that actually are cov- to change LCDs as needed Laws. https://www.ssa.gov/
ered by an NCD, or the LCD while they are in draft form OP_Home/ssact/title18/1869.htm.
is demonstrably inefficient and to modify them when Accessed June 29, 2017.
necessary through the 2. Centers for Medicare and Medicaid
toward or prejudicial to the Services. Medicare Program
physical therapy profession. reconsideration process. Integrity Manual Chapter 13—
In such instances, APTA and But it’s also important for Local Coverage Determinations.
clinicians to understand https://www.cms.gov/Regulations-
other applicable stakehold- and-Guidance/Guidance/
ers seek an “LCD reconsid- the determination process Manuals/downloads/pim83c13.
eration”—a written request to to ensure that they have all pdf. Accessed June 29, 2017.
necessary information and
10 PTinMOTIONmag.org / September 2017PTinMOTIONmag.org / September 2017 11
Ethics in Practice By Nancy R. Kirsch, PT, DPT, PhD
Is More Always Better?
Or is twice sometimes nice?
In an era in which budgetary consider- Shortly after a regional
VA administrator's visit to
ations and productivity concerns can his facility, Luke’s director
influence clinical practice, physical ther- calls a department meeting
and makes an announce-
apists (PTs) aren’t accustomed to being ment: She wants him and
directed to increase their time with the other PTs on staff to
see all patients with mus-
patients. But what might seem like a culoskeletal issues 3 times
Nancy R. Kirsch, PT, DPT, PhD,
good problem to have can have a down- per week. “I know from the
a former member of APTA’s Ethics monthly numbers that some
and Judicial Committee and a side. Consider the following scenario. of you sometimes are seeing
Catherine Worthingham Fellow patients less frequently,” she
Travel Bane or logistical burden to says. “When our regional
of the American Physical Therapy those who drive them.
Luke is a PT at a Veter- administrator was in town,
Association, is the program we got to talking, and we
ans Administration (VA) Luke’s solution has been,
director and a professor of physical facility in a rural area that determined that best prac-
in some cases, to reduce
therapy at Rutgers University serves a large geographic visit frequency from 3 tice argues for standardiz-
in Newark. She also practices in region. Luke enjoys the times a week to 2. He ing the number of weekly
northern New Jersey. work—especially the satis- has studied the literature visits for these patients at
faction of helping individ- and has determined that, 3. Because they are in the
uals who have served their for the musculoskeletal VA system, this won’t place
country to be as mobile and issues that bring some of a financial burden on them,
active as possible. his patients to the facility, and we’ll be better able to
there’s no significant ben- ensure that they’re getting
Getting to the VA center the best possible care from
efit to a third weekly visit
is a hardship for many of us. It’s a win-win situation.”
as long as he has maxi-
Luke’s patients. They often
mized the other visits and Luke raises his hand and
must travel great distances,
has provided the patient says, “Won’t that increase
which may impose a phys-
with a strong home exer- the travel burden for some
ical burden if they drive
cise program. patients?”
themselves, or a financial
12 PTinMOTIONmag.org / September 2017“Perhaps a bit,” Mary the fact that federal fund-
acknowledges. “But as ing shortages have forced
we all know, veterans are the closure of some VA
determined and resourceful facilities?”
people. Ensuring that we’re
providing them with the “Absolutely not!” Mary
highest quality care must exclaims. “This is entirely a
be our first priority.” patient-centered decision.”
Luke then notes that the Luke has been given a resources
literature suggests that directive, so he implements
equally efficacious results it with the patients he’s At www.apta.org/Policies/Practice/
can be achieved, in many been seeing twice weekly.
“Think of it as an added kk Standards of Practice for Physical Therapy
cases, with 2 weekly visits
rather than 3. A couple layer of care,” he tells them.
At www.apta.org/EthicsProfessionalism/
of his colleagues nod “And,” he self-deprecat-
affirmatively. ingly adds, “You get to see kk Core ethics documents (including the Code of
more of me each week for Ethics for the Physical Therapist and Standards
“With due respect,” Mary the duration of the care epi- of Ethical Conduct for the Physical Therapist
replies, “I know what the sode—an added bonus!” Assistant)
research says, and the
evidence is there for this For a while, Luke complies kk Ethical decision-making tools (past Ethics in
change.” She cites as exam- with Mary’s directive. But Practice columns, categorized by ethical principle
ples a pair of studies with soon, some of his patients or standard; the Realm-Individual Process-Situation
which Luke is familiar—nei- start asking him to please [RIPS] Model of Ethical Decision-Making; and
ther of which strike him as go back to a twice-weekly opinions of APTA’s Ethics and Judicial Committee)
definitive or particularly visits schedule, because the
extra driving each week— At www.apta.org/PTinMotion/2006/2/
compelling. EthicsinAction/
200 miles or more round-
At that point another PT, trip in some cases—is kk “Ethical Decision Making: Terminology and
Stella, asks, “Is this move proving to be burdensome. Context”
at all related to our overall At first, Luke holds his
utilization numbers, and ground. But then he starts
PTinMOTIONmag.org / September 2017 13Two
Column
Ethics in Practice
relenting on a case-by-case
basis, confident that the
Considerations and Ethical Decision-Making literature backs him up
and certain that, should
Luke has been asked to alter a treat- barrier—Mary’s opposition—to continu- Mary challenge him, he
ment schedule that he’s worked out ing on that course, this is an ethical can compellingly justify his
with a number of his patients based on distress for the PT. decision.
the ethical principle of beneficence—
doing what is best for the patient, Ethical principles. The following It doesn’t take long for this
based on his or her presentation principles of the Code of Ethics for pushback to come. At the
and specific needs. He does not feel the Physical Therapist offer Luke end of the first month that
that the mandated alteration models guidance: Luke has gone back to see-
beneficence. He’s not even certain ing several patients twice
kk Principle 2D. Physical therapists
that his director believes the revised weekly, Mary takes him
shall collaborate with patients/
treatment schedule really is necessary aside and says, “The latest
clients to empower them in deci-
from a patient-care standpoint. Still, he statistical report shows
sions about their health care.
is expected to comply or perhaps face that your visit numbers
consequences. This places him in an kk Principle 3A. Physical therapists are notably down. What’s
ethical bind. shall demonstrate independent and going on?”
objective professional judgment in
Realm. The ethical realm here is Luke starts to explain his
the patient’s/client’s best interest in
organizational. Mary has given Luke a rationale by talking about
all practice settings.
directive that she presents as benef- the travel hardships and
icent, but it seems to Luke not to be kk Principle 7A. Physical therapists citing relevant research
in the best interests of several of his shall promote practice environ- studies, but Mary quickly
patients. ments that support autonomous shuts him down. “More
and accountable professional treatment, better results, no
Individual process. Moral judgment judgments. additional cost to patients,”
is required of Luke, in that he feels he she says. “What is it about
has identified a right and wrong action kk Principle 8C. Physical therapists this policy that you don’t
and must decide which position to shall be responsible stewards of understand?”
stand behind. health care resources and shall
avoid overutilization or underutili- He wants to believe that
Ethical situation. Because Luke zation of physical therapy services. her motives are honorable
feels strongly that he knows the right and that this isn’t about
course of action but faces a structural physical therapy utilization
above all else. But even
if that’s the case, Luke
14 PTinMOTIONmag.org / September 2017believes that Mary is wrong proposed frequency and
on the science, and that duration, and implemen-
the needs of the individual tation of the plan of care.”
patient must be paramount Consider that sentence in
in any treatment plan. the context of the pre-
sented scenario.
“Look,” Mary continues in
a more conciliatory tone,
For Followup
“I understand where you’re
coming from. Getting here I encourage you to share
is a hike for many of our your thoughts about the
vets. I feel bad about that, issues raised in this sce-
but there’s no changing the nario by emailing me at
geography. All we can do is kirschna@shp.rutgers.edu
serve these patients the best or by posting a comment
way we know how. Okay?” online.
Luke knows what the ques- If you are reading the print
tion really means: “Are you version of this column,
down with the program, or go online to www.apta.
not?” He knows, too, that org/PTinMotion/2017/9/
his answer has implications EthicsinPractice/ for
for patient care and his a selection of reader
own sense of integrity. He responses to the scenario
considers his response. and my thoughts on those
responses. Scroll down
For Reflection to the heading “Author
Afternote.”
Standards of Practice for
Physical Therapy (see Be aware, however, that
resources box on page it takes a few weeks after
13 for the link) cites the initial print and online
elements of PTs’ plan of publication for feedback to
care. It states, in part, “The achieve sufficient volume
physical therapist involves to generate this online-
the patient/client … in the only feature.
planning, anticipated goals
and expected outcomes,
PTinMOTIONmag.org / September 2017 15The Real Story About
Chronic Fatigue
Syndrome
16 PTinMOTIONmag.org / September 2017Research shows that the Chronic fatigue syndrome (CFS) get off your own back, and wrap
has come a long way since the your head around this.”
condition, once ridiculed 1980s, when it was widely dis-
“What do you do with that?” she
as imaginary, is a true missed as “yuppie flu” and was
asks. “I decided that I needed to
suspected by many health care
physiological disease. providers of being a psycholog- figure out how to manage this on
my own.”
ical rather than a physiological
Here’s what to look for, condition. As luck or fate would have it, she
and how PTs are helping (A note on terminology: CFS goes soon happened upon—literally
dragged herself to—a symposium
those who have it. by at least 3 names, per the side-
bar on page 20. As CFS remains on CFS at an APTA Combined
the one by which the illness most Sections Meeting. What Rabanal
By Eric Ries widely is known, that’s the term learned that day in Anaheim,
PT in Motion is using.) California, led her to a treatment
relationship with the Salt Lake
Nicole Rabanal, PT, was among City-based Bateman Horne
the skeptics. Until late 2014 she Center, which specializes in CFS
considered “chronic fatigue and fibromyalgia.
syndrome” to be “a catch-all term
that meant medical science didn’t Today, her life is “all about pacing
know what the patient had or and management.” Rabanal, who
didn’t have.” owns Kinetic Energy Physical
Therapy in Steamboat Springs,
She changed her mind the Colorado, describes her highly
morning she woke up “feeling, regimented routine.
out of the blue, like I’d been hit
by a truck—with severe flu-like “I work a 2-hour shift in the morn-
symptoms, severe eye pain, ing,” she says. “I come home and
headache, ‘heavy’ head, muscle lie down in a quiet room—with
weakness, random numbness and oxygen, and with ice on my eyes
tingling sporadically throughout and head—for 4 hours. I go back
my body, and difficulty breathing to work for another 2-hour shift.
and swallowing.” This sudden I return home to again lie down
and dramatic shift in the then- with ice and oxygen. I get up and
46-year-old’s health led her on have dinner with my family, and
a year-long odyssey through am in bed no later than 8 pm.”
NICOLE RABANAL
the health care system, during On weekends, she continues, “I
which she saw 17 specialists and stay quiet all day, either lying
was at various times told she down or resting. On Sunday, I
had depression, Lambert-Eaton might get out and do something
myasthenic syndrome, and with my kids for an hour. But
myasthenia gravis. that’s it. There’s no going out to
When her fifth neurologist at eat, and only minimal socializing
last hit the nail on the head— with friends because prolonged
CFS is a diagnosis of exclusion talking is very draining for me.
for which there is no test—he I have significant sensitivity to
BECKY VOGSLAND light and sound, which greatly
told her, “Stop doctor-shopping,
PTinMOTIONmag.org / September 2017 17Rabanal has a message for her that CFS has a physiological
fellow PTs. basis—albeit an ill-defined one—and
“Typically you’re seeing patients
that it is a “serious, chronic, com-
based on their referral label being “We must know the criteria for plex, systemic disease that often
patients to meet this diagnosis—sig-
only part of the condition.” nificant reduction or impairment in
can profoundly affect the lives of
patients” and “requires timely and
– TODD DAVENPORT ability to engage in pre-illness activ- appropriate care.”
ity levels, accompanied by fatigue,
limits the surroundings in which I for more than 6 months; post-exer- CFS affects between 836,000 and
place myself.” tional malaise; unrefreshing sleep; 2.5 million Americans, according to
and either cognitive impairment or the Centers for Disease Control and
The upside, if you want to call it orthostatic intolerance. Because if Prevention (CDC). But that’s really
that, has been the demonstrated we aren’t correctly identifying this only a guess, the agency concedes,
value of Rabanal’s professional patient population, it’s easy to push as “an estimated 84% to 91% of
training. patients into a treatment or exer- people with CFS have not been
cise program that will make their diagnosed. 2
“The knowledge and experience
condition worse. They are likelier
of having been a PT for nearly 25 What causes it? This also is
to be noncompliant, disinclined to
years has been incredibly helpful hazy. As APTA summarizes in
follow up with care, and present as
to my personal treatment plan,” its consumer-oriented “Physical
a returning patient whose condition
Rabanal says. “Listening for and Therapist’s Guide to Chronic
never seems to improve.”
understanding the signs of when Fatigue Syndrome, 3 “Many
I’m pushing beyond my energy There is a great deal that PTs can researchers suspect impairment
limitations, then implementing do to help patients with CFS of all of the aerobic energy, immune,
appropriate exercise and stretching, severity levels, say those who PT in and gastrointestinal systems may
is a big part of the management Motion contacted for this article. It be responsible for the functional
puzzle. This of course is what PTs begins with listening and a thor- impairment experienced in indi-
do every day with patients, in one ough patient interview and extends viduals with this condition.” The
form or another—we listen closely through education, individualized Mayo Clinic advises that CFS may
and apply our knowledge to their goal-setting, pacing, movement and be caused by “a combination of
presentation and what we learn strengthening exercises, manual factors that affect people who were
from them.” therapy, and appropriate referral. born with a predisposition to the
disorder.”4 Factors that have been
“I’ve made significant modifications What PTs can offer, too, is what studied, Mayo notes, include viral
to my treatment style,” Rabanal people with CFS arguably need the infections, immune system disor-
adds. “I sit a lot, and lean or move most, says Jessie Podolak, PT, DPT, ders, and hormonal imbalances.
to help manage my orthostatic owner of Phileo Health in Altoona,
intolerance—which does not allow Wisconsin, and a certified therapeu- Todd Davenport, PT, DPT, MPH,
me to stand still, unsupported, for tic pain specialist. “We can bring edited the APTA consumer guide
more than 5 minutes. I co-treat with them hope.” to CFS and has conducted research
other therapists in my clinic to per- on the disease. He also long has
form manual techniques that I no
longer can do because of my limited Putting 2 and 2 been active with the Workwell
Foundation—a Ripon, California,
strength. During my work periods, I
use a Fitbit to monitor my heartrate
Together based nonprofit that researches
functional aspects of the disease
and its silent timer to remind me A turning point for those facing
and conducts cardiovascular and
when take my medications.” CFS came in 2015, when the
pulmonary exercise testing to
Institute of Medicine issued an
determine and document postex-
“It’s a huge challenge,” she says. extensively researched report on
ertional malaise and symptom
“But I love what I do, so I’m deter- the disease subtitled “Redefining
exacerbation after physical activity.
mined to make it work.” an Illness.”1 It firmly established
18 PTinMOTIONmag.org / September 2017The Basics
DESCRIPTION
Chronic fatigue syndrome (CFS) is a devastating and complex disorder. People
with CFS have overwhelming fatigue and a host of other symptoms that are
not improved by bed rest and that can worsen after physical activity or mental
exertion. They often function at a substantially lower level of activity than they
were capable of before they became ill.
Besides severe fatigue, other symptoms include muscle pain, impaired mem-
Per the CDC’s figures on diagnosis,
ory or mental concentration, insomnia, and postexertion malaise lasting more
it is atypical, Davenport notes, for
than 24 hours. In some cases, CFS can persist for years.
PTs to get patients who’ve been
referred by physicians with a Researchers have not yet identified what causes CFS, and there are no tests to
diagnosis of CFS. diagnose CFS. Moreover, because many illnesses have fatigue as a symptom,
doctors need to take care to rule out other conditions, which may be treatable.
“Typically you’re seeing patients
based on their referral label being www.cdc.gov/cfs/general/index.html
only part of the condition,” says
Davenport, an associate profes- PREVALENCE
sor and program director of the CFS affects 836,000 to 2.5 million Americans. An estimated 84%–91% of people
Department of Physical Therapy with CFS have not been diagnosed, meaning the true prevalence is unknown.
at the University of the Pacific CFS affects women more often than men. The average age at onset is 33, but it
in Stockton, California, and a has been reported in patients younger than 10 and older than 70.
board-certified clinical specialist in
orthopaedic physical therapy. “So, www.nap.edu/read/19012/chapter/1
the referral may be for ‘widespread
bodily pain.’ Or, perhaps the patient DIAGNOSTIC CRITERIA
has noticed a functional decline Diagnosis requires that the patient have 1 of the following 3 symptoms:
and has been talking to his or her
primary care physician about a 1. A substantial reduction or impairment in the ability to engage in pre-ill-
fatigue issue. That individual, then, ness levels of occupational, educational, social, or personal activities that
may be referred with a diagnosis of persists for more than 6 months and is accompanied by fatigue, which is
deconditioning.” often profound, is of new or definite onset (not lifelong), is not the result of
ongoing excessive exertion, and is not substantially alleviated by rest,
It’s imperative on the PT, therefore,
“to put 2 and 2 together—to deter- 2. Postexertional malaise,* and
mine whether the patient may have 3. Unrefreshing sleep.
CFS and might, therefore, require
appropriate management strate- At least 1 of the 2 following manifestations also is required:
gies,” Davenport says.
1. Cognitive impairment* or
One of the stated aims of an
2. Orthostatic intolerance.
analysis that Davenport and his
Workwell colleagues published in *Frequency and severity of symptoms should be assessed. The diagnosis of ME/CFS should
Physical Therapy in 20105 was to be questioned if patients do not have these symptoms at least half of the time with moderate,
substantial, or severe intensity.
discuss aerobic system deficits that
may lead to the clinical presentation www.nap.edu/read/19012/chapter/1
of CFS. “Where the literature seems
Seeking and receiving a diagnosis can be a frustrating process for several
reasons, including skepticism of health care providers about the serious nature
of CFS and the misconception that it is a psychogenic illness or even a figment
of the patient’s imagination. Less than one-third of medical schools include
CFS-specific information in the curriculum, and only 40% of medical textbooks
include information on the disorder. It often is seen as a diagnosis of exclusion,
which also can lead to delays in diagnosis, or to misdiagnosis of a psycholog-
ical problem. Once diagnosed, patients frequently complain that their health
care providers do not know how to deliver appropriate care for their condition
and often subject them to treatment strategies that exacerbate their symptoms.
JESSIE PODOLAK www.nap.edu/read/19012/chapter/2
PTinMOTIONmag.org / September 2017 19That’s What She SEID (About the Name)
“Trivializing.” “Stigmatizing.” “A disservice to many The words “systemic exertion intolerance disease” do
patients.” “Does not accurately describe the major features not exactly roll off the tongue, agrees Nicole Rabanal, PT.
of the disease.” Nevertheless, she personally has experienced the new
name’s ability to positively alter perceptions.
Those are some of the ways the Health and Medicine
Division of the National Academies of Science, Rabanal, who owns Kinetic Energy Physical Therapy in
Engineering, and Medicine (formerly the Institute of Steamboat Springs, Colorado, was diagnosed in late 2014
Medicine), in a highly publicized 2015 report, character- with CFS, an illness that has greatly circumscribed her
ized the name of the medical condition commonly known personal and professional life. Nevertheless, she says,
as chronic fatigue syndrome (CFS). “When people ask me, ‘What’s wrong with you? Did they
ever figure it out?’ and I say, ‘I have chronic fatigue,’ they
Ronald Davis, PhD, a biochemist who heads the Genome pat me on the shoulder and say, ‘Oh, you’ll be okay. Just lie
Technology Center at Stanford University, hit on the crux of down and rest.’”
the problem in an interview with Science magazine after the
report’s release. “My son is sick with [CFS], and when I tell Such reactions, she says, are “devastating—the stigma is
people, they say, ‘I had that once’ because they were tired horrible.” But when Rabanal instead replies that her diag-
once,” a frustrated Davis remarked.1 nosis is an illness called systemic exertional intolerance
disease, the response is, “My gosh, that’s awful! What can
The disease also sometimes is called myalgic encephalo- I do for you? How can I help you?”—even though it’s clear
myelitis (ME), CFS/ME, or ME/CFS. “ME is a better name,” that the questioner hasn’t a clue what the term means.
Davis told the magazine—but, he observed, “there are no Sometimes a simple lack of pejorative association makes all
real data to fit [it].” the difference.
Davis was on the committee that compiled the 2015 report, The trick going forward, Rabanal says, will be to teach
titled “Beyond Myalgic Encephalomyelitis/Chronic Fatigue both the public and still-skeptical members of the medical
Syndrome: Redefining an Illness.”2 After reviewing more community that a condition they may underappreciate or
than 9,000 scientific studies, weighing expert testimony, even dismiss under the CFS/ME moniker is one and the
and soliciting public input, the panel concluded not only same with the scientifically validated disease that more
that “ME/CFS is a serious, chronic, complex, and systemic accurately has been rechristened SEID.
disease that frequently and dramatically limits the activities
of affected patients” and that merits new diagnostic criteria, “If you can’t make that connection, there’s no validation for
but also that the words commonly used to describe the the thousands upon thousands of people who are afflicted
illness are offensive in the case of chronic fatigue syndrome with this disease,” Rabanal argues. “This patient population
and inaccurate in the case of myalgic encephalomyelitis. has to be validated in its suffering, which can be extensive.
Education is the only way to do that.”
Regarding ME, the report read, “The committee concludes
that the term ‘myalgic encephalomyelitis’ is inappropriate “Names change all the time,” observes Adriaan Louw, PT,
because there is a lack of evidence for encephalomyelitis PhD. He has worked clinically with people with chronic pain
(brain inflammation) in ME/CFS patients, and myalgia for 25 years and is president of the International Spine and
(muscle pain) is not a core symptom of the disease.” Pain Institute. What’s most important for PTs to do, Louw
says, is encapsulated in the title of a presentation he gave
The new term the panel chose to describe the illness was in February at APTA’s Combined Sections meeting in San
“systemic exertion intolerance disease,” or SEID. “This Antonio, Texas.
name,” the panelists wrote, “captures a central characteris-
tic of the disease: the fact that exertion of any sort—physical, In that talk, which focused on how PTs best can understand
cognitive, or emotional—can adversely affect patients in CFS and other persistent pain disorders, Louw emphasized
many organ systems and in many aspects of their lives.” the need to base clinical decision-making not on general-
ized protocols and preconceived notions, but on the indi-
While SEID—a term that has yet to capture the public’s vidual’s specific presentation and information the clinician
imagination—has accuracy on its side, even Davis concedes has culled from extensive patient interviewing. He titled it
its descriptive flatness. “It’s hard to come up with a good “Treat the Patient, Not the Label.”
name, and I don’t think this is a perfect name,” he told
Science 2 years ago.
REFERENCES
1. Cohen J. Goodbye chronic fatigue syndrome, hello SEID. Science. February 10, 2015. www.sciencemag.org/news/2015/02/goodbye-chronic-fatigue-syndrome-hello-
seid. Accessed June 19, 2017.
2. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining and Illness. Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic
Fatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine. Washington, DC: National Academies Press; 2015.
20 PTinMOTIONmag.org / August 2017to be relatively strong,” Davenport he advises. “You’re going to be
says, “is in the etiology that there seeing these patients for months
are aerobic system impairments and years—albeit less frequently, for
in people with CFS/ME.” (“ME” the most part, as time goes on.”
stands for myalgic encephalomy-
elitis; see the sidebar on the facing Davenport concedes that this
page). “We’re not sure why this “go-slow” approach can seem
is. We just know that the aerobic counterintuitive when “exercise is
system is not as effective in these our wheelhouse as PTs” and “a lot of
individuals.” forms of fatigue are seen as varia-
tions on deconditioning.” Presented
This information is instructive for with a patient who is tired, “we PTs
PTs, Davenport says. “If you start want our exercise tool to work well.”
with the assumption that the aero- He cautions, however, that, “We’re “capturing quite well the complex-
bic system is impaired, that guides employing the wrong tool for the ity of CFS” and the importance
what PTs should do. The first step is job if we’re pushing graded exercise of building patient strength and
to teach patients about activity pac- and telling patients that they just endurance from an anaerobic
ing that will keep them within the need to get up and get moving.” foundation.
limits of their symptoms. We don’t He cites as a cautionary tale the
want people going to Costco and infamous-in-CFS-circles PACE “When an individual gets that
then being zonked out for the rest of study of 2011,6 which essentially super-malaise from exertion, that
the week. So, we advocate for people suggested that a combination of can foster kinesiophobia, or fear of
to look at the peaks and valleys of psychotherapy and exercise might movement,” Keeton notes. “If you
their daily activities and saw off the be the CFS patient’s best friends. It can empower the patient to find
peaks—using that energy to help fill caused an uproar in the scientific movements that don’t trigger that,
in the valleys.” community over its methodology while correlating to patient-iden-
and conclusions, and was famously tified problems and impairments
“The second step,” he continues, eviscerated on the Virology Blog,7 a that you’ve noted, your therapeutic
“is to train people in lower-level popular online resource for dissem- alliance with that patient improves,
anaerobic activities that register ination of knowledge about viruses
under the ventilatory threshold for and viral disease.
aerobic activation and take less
than 2 minutes. Focus on stretch- “To me,” Davenport says, “best
ing and gentle exercise, with the practice with this patient pop-
aid of a heartrate monitor that’s ulation, as with all patients we
set below the ventilatory threshold see as PTs, comes back to good,
and can alert the patient when that old-fashioned listening—taking on
threshold has been exceeded and good faith what the patient what
rest is needed.” the patient has to say, and going on
from there.”
Finally, Davenport says, “the
last piece is to get patients into “One of our great advantages is
longer-duration activities by way The Power of
the physical connection we have
of gradually building on anaerobic
training—while recognizing that Listening with our patients. We’re in a unique
the prognosis for full functional Ben Keeton, PT, DPT, director of
recovery is very guarded and clinical operations at The Jackson position as PTs to add a positive
limited.” Anaerobic threshold Clinics in northern Virginia, lauds connotation to movement in the
training and pacing “aren’t going to the 2010 Physical Therapy piece
that Davenport lead-authored as
case of people with CFS.”
‘fix’ impaired aerobic metabolism,”
– BEN KEETON
PTinMOTIONmag.org / August 2017 21therapists can offer them. But it all their chronic fatigue, so that you
starts with the patient interview,” then can guide them toward greater
Louw says. “Ninety percent of function and more energy.” The
our patients with chronic fatigue owner of Zang Physical Therapy
syndrome start crying during this in Lemoyne, Pennsylvania, he’s a
process, simply because we’re board-certified clinical specialist in
spending time with them, taking orthopaedic physical therapy and
them seriously, and demonstrating a fellow of the American Academy
that we care about them as human of Orthopedic Manual Physical
beings.” Louw, who is based in Iowa, Therapists.
has worked clinically with people
“I have treated these patients and with chronic pain for 25 years and is “Active listening by the physical
therapist is key,” echoes Becky
conducted research on them, and president of the International Spine
Vogsland, PT, DPT, who coordi-
and Pain Institute, which offers
there are so many things that continuing education courses and nates the Comprehensive Pain
therapists can offer them. But it all certifications. Center of the Minneapolis VA
Health Care System and is a
starts with the patient interview.” “If they don’t cry during the subjec- board-certified clinical specialist
– ADRIAAN LOUW tive exam, they often do during the in orthopaedic physical therapy.
physical one,” he says. “They’ll say, “To borrow a term from our
along with the prognosis. That’s ‘That’s the most thorough medical psychology colleagues, follow the
very powerful.” exam I’ve had in 10 years.’” ‘VEMA’ model: validate, educate,
motivate, activate.”
Keeton, a board-certified clinical “People who are in chronic pain
tend to look ‘normal’ to others, and
specialist in orthopaedic physical
therapy, adds that the value of the often feel disbelieved and very Achieving Goals
“physical” part of what physical isolated,” notes Jessie Podolak. PTs who treat patients with CFS
therapists do can’t be understated “It’s huge when we encourage must leaven their messages of
with this patient population. them to tell their whole story and hope with acknowledgement
say, ‘I hear and understand you.’ that improvement likely will be
“One of our great advantages is the It’s important that we explain incremental and recovery far from
physical connection we have with what’s happened to them in a complete. They therefore are reluc-
our patients,” he says. “We’re in way that makes sense—that we tant to recount memorable “success
a unique position as PTs to add a say, ‘There’s been a tipping point, stories” without asterisks—even
positive connotation to movement a shift in your homeostasis, but while acknowledging the signifi-
in the case of people with CFS. things will get better, and I’ll sup- cance of relative improvements.
Passive or assisted active range of port you throughout the process.”
motion, where there’s good quality Keeton cites a patient who’d expe-
of contact and the practitioner has “You have to be present with rienced chronic back pain for 20
strong manual therapy skills, builds patients with CFS,” is how Andrew years and had been diagnosed with
that trust that moving won’t hurt—or Zang, PT, DPT, puts it. “You need CFS as a comorbid condition. “This
at least that it won’t hurt as much.” to learn as much as you can about may sound underwhelming,” he
what they can and can’t do, what says, “but at the end of 12 weeks in
The first step in all this, according their goals are, and what their physical therapy her baseline pain
to Adriaan Louw, PT, PhD, goes perception is of why they can’t do level was down from 6 or 7 all day
back to Davenport’s comments things. You almost need to be part on a 10 scale to 3 or 4. That made
about “old-fashioned listening.” psychologist, to ensure that they a big difference in her life. We
get the most out of their treatment created a plan of care to conserve
“I have treated these patients and
sessions. You need to help them energy and restore mobility. We
conducted research on them, and
understand the ‘what’ and ‘why’ of incorporated all of the manual
there are so many things that
22 PTinMOTIONmag.org / September 2017therapy and exercise components Podolak has been seeing a patient
necessary to manage the low with CFS for the past 2 years who,
back pain, but we did it within the at the outset, could walk only 50 “You need to help them understand
context of chronic fatigue—with an feet—“if that.” He loves nature and
eye to functional activity.” had sorely missed walking outside, the ‘what’ and ‘why’ of their
so she’s helped get him to the point chronic fatigue, so that you then
The patient had been an avid that he now can walk around a local
kayaker earlier in her life. “After 10 can guide them toward greater
park for 10 minutes. “That was a
years of no kayaking, it was a pretty very meaningful goal for him to function and more energy.”
big celebration when she paddled meet,” she says.
her first tenth of a mile,” Keeton – ANDREW ZANG
says. “It was very rewarding for me The next goal will be enabling him
as a PT. She’s empowered now to to make short drives downtown and comorbidity in this patient popula-
make her own decisions about how decrease his isolation, Podolak says. tion of which PTs should be aware.
to manage her exertion and budget Socialization should help combat If it’s present, is the patient being
her energy. What she said to me his depression issues, she notes, treated for it? Ask questions.”
was, ‘I either could maintain a pain adding, “Depression is a common
level of 3 or 4 and just do my daily
life stuff, or I could maintain that
pain level, do my daily life stuff a
little bit less, and use that energy to
hit the water. I choose water.’”
Louw recalls a frank exchange
he had with a stay-at-home mom
with CFS who struggled daily with
fatigue and pain in order to meet
her family’s needs. “While her hus-
band and kids were eating dinner,
she was crying in bed by herself,”
he says.
“I explained that she must space
out her activities, take breaks, and
make other adjustments. She told
me her life was too busy to do that.
I responded, ‘You don’t have a life,’”
Louw recounts.
“I wasn’t trying to be rude,” he
emphasizes. “I just meant that the
way she was living was not the way
anyone should have to live. She
looked at me and said, ‘Wow, it isn’t
[a life].”
After making the necessary adjust-
ments, that patient ultimately was
able to enjoy dinner with her family,
while “in very little if any pain,”
says Louw.
PTinMOTIONmag.org / September 2017 23Resources
GENERAL
Physical Therapist’s Guide to Chronic Fatigue Syndrome
kk www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=13f232c1-
2d06-4063-8a3b-5ae844fdd075
Centers for Disease Control Toolkit for Providers
kk www.cdc.gov/cfs/pdf/cfs-toolkit.pdf
Mayo Clinic The Future
kk www.mayoclinic.org/diseases-conditions/chronic-fatigue-syndrome/
Exactly how bright the future looks
basics/definition/con-20022009
for people with CFS in terms of
Workwell Foundation: Research on Chronic Fatigue Syndrome finding answers through research
kk www.workwellfoundation.org/ depends on who you talk to.
Bateman Horne Center for ME/CFS and Fibromyalgia Louw is particularly encouraged
kk https://batemanhornecenter.org/ by the body of work of Belgian
researchers Mira Meeus and Jo
ARTICLES Nijs, with whom he’s collaborated,
“The Tragic Neglect of Chronic Fatigue Syndrome” calling them “world-leading
kk www.theatlantic.com/health/archive/2015/10/chronic-fatigue-patients- authorities in the field of neuro-
push-for-an-elusive-cure/409534/ science and people with chronic
fatigue syndrome.” Their work, he
“Goodbye Chronic Fatigue Syndrome, Hello SEID” says, suggests that a “mid-range”
kk www.sciencemag.org/news/2015/02/goodbye-chronic-fatigue-syndrome- of exercise is best, with no exercise
hello-seid or too much exercise both making
the patient’s condition worse.
“A New Name, and Wider Recognition, for Chronic Fatigue Syndrome”
Their research, Louw says, “is very
kk www.newyorker.com/tech/elements/chronic-fatigue-syndrome-iom-report
therapy-specific. I encourage PTs to
look up their papers.”
REPORTS AND REVIEWS
“Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Davenport, however, argues that a
Redefining an Illness” “pain science approach” sometimes
kk www.nap.edu/read/19012/chapter/1 can underplay the value of patients
“listening to their body” in favor of
“Exercise As Treatment for Patients with Chronic Fatigue Syndrome” the message that “pain perception
kk www.cochrane.org/CD003200/DEPRESSN_exercise-treatment-patients- does not equal tissue damage.” It’s
chronic-fatigue-syndrome an area in which, he says, “pain
science proponents and I have
SELECTED RESEARCH some robust debate.”
Davenport TE, Stevens SR, Van Ness JM, et al. Conceptual model for
physical therapist management of chronic fatigue syndrome/myalgic He adds that while “some interest-
encephalomyelitis. Phys Ther. 2010;90(4):602-614. ing papers have come out in recent
years that seem to support the
Hornig M, Montoya JG, Klimas NG, et al. Distinct plasma immune signatures etiology of possible aerobic-system
in ME/CFS are present early in the course of the disease. Sci Adv. 2015;1(1). dysfunction” in people with CFS,
a “causal link” to why CFS hap-
Nagy-Szakal D, Williams BL, Mishra N, et al. Fecal metagenomic profiles
pens—and thus how it might best be
in subgroups pf patients with myalgic encephalomyelitis/chronic fatigue
addressed—remains elusive.
syndrome. Microbiome. 2017;5:44.
Nicole Rabanal, meanwhile, follows
Snell CR, Stevens SR, Davenport TE, Van Ness JM. Discriminative validity of
developments in CFS research with
metabolic and workload measurements for identifying people with chronic
all the intensity that her disease
fatigue syndrome. Phys Ther. 2013;93(11):1484-1492.
will allow. She is encouraged by
Stevens SR, Davenport TE. Functional outcomes of anaerobic rehabilitation in what she sees.
a patient with chronic fatigue syndrome: case report with 1-year follow-up.
“Tremendous research is being
Bulletin of the IACFS/ME. 2010;18(3):93-98.
conducted around the world,” she
Van Cauwenbergh D, De Koonung M, Ickmans K, Nijs J. How to exercise says. “In Norway they’re looking
people with chronic fatigue syndrome: evidence-based practice guidelines. at rituximab”—a medication used
Eur J Clin Invest. 2012.42(10):1136-1144.
24 PTinMOTIONmag.org / September 2017You can also read
