Why should ME/CFS-patients be cautious with physical exercise?

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Why should ME/CFS-patients be cautious with physical exercise?

Who risks decline after a forced reconditioning program?

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Most ME/CFS-patients have chronically activated immune systems, as is the

case in Rheumatoid Arthritis patients. This problem is not detected in

routine laboratory tests because these are mainly indicators for

inflammation and do not reveal an altered 'innate immunity'.

Nevertheless, there are laboratory tests available which indicate the

presence of these maladjustments and which worsen under the influence of

physical exertion. The parameters are: hCRP (high sensitivity CRP), elastase

(index of immune activity), NO (nitric oxide) and presence in the serum of

DNA, RNA, LPS (lipopolysaccharides), and/or antibodies for bowel bacteria in

the blood.

If ME/CFS-patients are systematically examined for these markers, one finds

that the majority of them have one or more abnormal values, and it is

therefore probable that they will have a slow recovery after physical

exercise. Furthermore, patients will sometimes feel worse after exertion

because the underlying anomalies continue to become worse as a consequence

of the physical exertion.

The case of nitric oxide (NO) is interesting. As a result of disruption in

normal bowel flora in these patients, there is sometimes an increased

NO-production by these bacteria. Also, due to an activated nonspecific

immune system, the enzyme iNOS is responsible for higher NO-values in the

serum. This, among other things, is responsible for a lowered blood pressure

because it expands the larger blood vessels. As a result, the peripheral

blood vessels must contract, which causes a maladapted circulation in

different parts of the body.

Nitric monoxide, or simply NO, plays an important role in physical exertion.

An acceleration of the heartbeat causes the blood flow to increase. As a

response to this, endothelial cells trigger a number of processes to raise

the production of NO. This leads to several processes which raise

NO-production and activity and keep it going: the eNOS (endothelial enzyme

that stimulates NO-production) becomes more active and there is a drop in

the inactivation of NO caused by a decrease in production of free oxygen

radicals and by activation of the anti-oxidizing ESA. NO is toxic for

natural killer cells and T-cells because they lose their ability to function

if there is too much NO circulating. This is one of the reasons why

ME/CFS-patients easily become ill after they have engaged in physical

activity.

Sports is beneficial to healthy individuals because NO has a protective

impact against arteriosclerosis and bacterial infections. However, an excess

of NO is detrimental and patients should be advised that physical exertion

has been shown to lead to a build up of NO in people suffering from ME/CFS.

Furthermore, these patients show exercise intolerance because the blood

supply cannot adapt to the increased exercise-induced demand for oxygen in

the tissues .

The case of NO is just one of the many imbalanced systems which create

exercise intolerance and/or delayed recovery. Typically, an ME/CFS-patient

of the Rheumatoid Arthritis type will have a much lower exercise capacity 24

hours after undergoing an exercise test till exhaustion. Also, a lot of

patients do not reach their target heart rate when they are pushed to

perform an exercise test, due to muscle weakness or pain in the lower

extremities. This muscle weakness is a result of the binding of NO to the

ryanodine receptors in the muscles. The pain is a result of maladapted blood

flow in the muscles of the same extremities, which results in a premature

accumulation of lactic acid. A portion of the NO will oxidize: NO + O2 ->

ONOO - (peroxynitrate). This is a very strong free radical which damages

cell membranes.

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What can we learn from this ?

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ME/CFS-patients must *never *be forced to do compulsory exercise; they must

listen to their bodies and not to other people who think they know better

but are not familiar with the biology of these disorders. Physical exercise

must be adapted to the individual, based on the severity and consequences of

the illness. Therefore, the individual patient evaluation should be

extensive, specific and adapted to the disorder.

Leo Trower

*References:*

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. Ito et al. Cell.Immunol. 1996 : 174 ; 13

. Englebienne & De Meirleir 2002 - book (291 pages) - CRC press

. Mihylova et al. Neuro.Endocrinol.Letters 2007 : 11 ; 28

. Connolly et al. J.Appl.Physiol. 2004 : 97 ; 1461

. Sobko et al. Free Radical Biology & Medicine 2006 : 41 ; 985

. VanNess et al. J. Chronic Fatigue Syndrome 2007 : 14(2) ; 77