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  • Guest Blog: Dr. Peter Rowe – Is The Physical Examination Normal in CFS? Part 3

Guest Blog: Dr. Peter Rowe – Is The Physical Examination Normal in CFS? Part 3

In this 3rd piece of our three-part blog series Dr. Peter Rowe discusses range of motion in ME/CFS patients.

In the first post in the series, Dr Rowe discussed orthostatic heart rate and blood pressure changes. Read Part 1 HERE

In the second post, Dr Rowe discussed joint hypermobility. Read Part 2 HERE


Postural dysfunctions and movement restrictions

Some of those with joint hypermobility also have postural abnormalities that are thought to be a consequence of the effect of gravitational loading of the spine, including a head-forward posture, a rounded appearance of the thoracic spine, and increased lumbar curvature. My physical therapist colleague, Rick Violand, had originally identified a number of associated areas of reduced movement of the spine and limbs during his examination of those with CFS. These observations describing adverse neural tension (also termed neurodynamic dysfunction) have been reported elsewhere.1-3 During the clinical care of patients over the last decade, we had been struck by how many individuals with CFS had focal areas of restricted range of motion, and how adding an elongation strain to nerves and soft tissues could aggravate their typical CFS symptoms. With other co-investigators, we recently published a large study showing that reduced range of motion of the limbs and spine was significantly more common in adolescents and young adults with CFS than in carefully matched controls, and that adding a longitudinal strain to the nerves and soft tissues was another way of provoking common CFS symptoms.18 These examination abnormalities can be detected most readily by physical therapists and other manual practitioners. Physicians and nurse practitioners can become adept at screening for these problems if provided with extra training.

Why does the detection of movement restrictions matter? Our experience leads us to believe that the areas of adverse neural tension are treatable. In clinical care we have noted that improvement in the range of motion is usually accompanied by improvement in daily function for those with CFS. Much more work needs to be done to characterize these abnormalities further, to determine whether the same changes are also present in adults with CFS, and to identify the optimal treatment approaches. These observations open up new avenues for understanding the pathogenesis of CFS symptoms, and for further individualized approaches to treatment. We hypothesize that treating the movement restrictions first using gentle manual therapy techniques will help the most impaired CFS patients begin to tolerate exercise better.


These three related areas of dysfunction—circulatory disturbances, joint hypermobility, and movement restrictions—emphasize that there is much to be gained from the performance of a careful clinical examination in those with CFS. Given that aspects of each abnormality are treatable, their identification has the potential to improve the daily symptoms and function for those with CFS. We recommend the more widespread adoption of maneuvers to ascertain for these abnormalities in the clinical and research evaluation of those with CFS.


 As medicine becomes more and more dependent on sophisticated technology, the physical exam is in danger of becoming a lost art.  As Dr. Peter Rowe, Johns Hopkins University, has laid out in this three-part series, there is much to be learned in a physical exam in CFS. Our hope is that this information will be of great value to both you and your doctor. We believe it clearly illustrates the value of laying on of hands in the physical examination of ME/CFS.

Suzanne D Vernon, PhD
Solve ME/CFS Initiative Scientific Director



  1. Rowe PC, Fontaine KR, Violand RL. Neuromuscular strain as a contributor to cognitive and other symptoms in chronic fatigue syndrome. Frontiers in Integrative Physiology 2013; Front Physiol 2013;4:115. doi: 10.3389/fphys. 2013.00115
  2. http://www.research1st.com/2013/01/25/manual-therapy-1-of-2/
  3. http://www.research1st.com/2013/02/01/manual-therapy-2-of-2/
  4. Rowe PC, Marden CL, Flaherty M, Jasion SE, Cranston EM, Johns AS, Fan J, Fontaine KR, Violand RL. Impaired range of motion of limbs and spine in chronic fatigue syndrome. J Pediatrics 2014 (in press).


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