http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(5): 465 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.952453
LETTER TO THE EDITOR
Harms and benefits associated with exercise therapy for CFS/ME Robert Courtney
Gladwell et al. suggest that the harm reported by chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients, in surveys, after receiving graded exercise therapy (GET) in clinical settings, is not replicated in research studies and may be linked to the poor quality of the therapy being administered and therapy that does not adhere to NICE guidelines [1]. However, Kindlon extensively explored the published research data, in relation to harms associated with GET for CFS/ME, and concluded that peer-reviewed reporting of harms data have not been systematic enough to make any firm conclusions about adverse effects from GET. Based on the inadequacy of existing published data, Kindlon suggests that the possibility of harm after treatment with GET for CFS/ME patients in research studies cannot be ruled out. Furthermore, harms reported in surveys have been consistent [2]. The therapeutic benefits of GET for CFS/ME are limited. A Cochrane meta-analysis concluded that the benefits of exercise therapy for CFS/ME patients are non-significant at six-month follow-up [3]. The PACE trial, an open-label randomised trial (with no placebo control), and the largest trial of its type, demonstrated that when GET is added to specialist medical care (SMC), it leads to no significant improvement in employment hours, welfare benefit claims or private insurance claims [4]. For the selfreported primary outcomes (Chalder fatigue and SF-36 physical function), there was a moderate effect size for GET, and the improvement rates were 15% and 12% (i.e. the additional proportion of participants who achieved a clinically useful improvement when GET was added to SMC). The absence of actigraphy monitoring during the trial means that a truly objective measure of changes in physical activity was not included, but the six-minute walking distance test demonstrated a modest average improvement in physical disability when GET was added to SMC [5]. For the PACE trial, GET was designed to treat and ‘‘reverse’’ maladaptive avoidant behaviour, exercise intolerance and deconditioning which, it was hypothesised, cause or propagate
Address for correspondence: Robert Courtney. E-mail: information785@ gmail.com
CFS [6,7]. White et al. concluded: ‘‘Our finding that studied treatments were only moderately effective also suggests research into more effective treatments is needed’’ [5]. Given the disappointing results of the trial, the tested hypotheses (e.g. deconditioning etc.) were found wanting and suggest that impairments in CFS/ME are largely due to a different mechanism.
Declaration of interest The author reports no declaration of interest.
References 1. Gladwell PW, Pheby D, Rodriguez T, Poland F. Use of an online survey to explore positive and negative outcomes of rehabilitation for people with CFS/ME. Disabil Rehabil 2014;36:387–94. 2. Kindlon T. Reporting of harms associated with graded exercise therapy and cognitive behavioural therapy in myalgic encephalomyelitis/chronic fatigue syndrome. Bull IACFS/ME 2011;19: 59–111. 3. Edmonds M, McGuire H, Price J. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev 2004:CD003200. 4. McCrone P, Sharpe M, Chalder T, et al. Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis. PLoS One 2012;7:e40808. 5. White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011;377:823–36. 6. Bavinton J, Darbishire L, White PD; On behalf of the PACE trial management group. PACE manual for therapists: graded exercise therapy for CFS/ME. Final Trial Version Version 7. [Internet] PACE Trial; 2011. Available from: http://www.pacetrial.org/docs/gettherapist-manual.pdf [last accessed 10 Sep 2013]. 7. White PD, Sharpe MC, Chalder T, et al. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol 2007;7:6.
Copyright of Disability & Rehabilitation is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LETTER TO THE EDITOR
Harms and benefits associated with exercise therapy for CFS/ME Robert Courtney
Gladwell et al. suggest that the harm reported by chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients, in surveys, after receiving graded exercise therapy (GET) in clinical settings, is not replicated in research studies and may be linked to the poor quality of the therapy being administered and therapy that does not adhere to NICE guidelines [1]. However, Kindlon extensively explored the published research data, in relation to harms associated with GET for CFS/ME, and concluded that peer-reviewed reporting of harms data have not been systematic enough to make any firm conclusions about adverse effects from GET. Based on the inadequacy of existing published data, Kindlon suggests that the possibility of harm after treatment with GET for CFS/ME patients in research studies cannot be ruled out. Furthermore, harms reported in surveys have been consistent [2]. The therapeutic benefits of GET for CFS/ME are limited. A Cochrane meta-analysis concluded that the benefits of exercise therapy for CFS/ME patients are non-significant at six-month follow-up [3]. The PACE trial, an open-label randomised trial (with no placebo control), and the largest trial of its type, demonstrated that when GET is added to specialist medical care (SMC), it leads to no significant improvement in employment hours, welfare benefit claims or private insurance claims [4]. For the selfreported primary outcomes (Chalder fatigue and SF-36 physical function), there was a moderate effect size for GET, and the improvement rates were 15% and 12% (i.e. the additional proportion of participants who achieved a clinically useful improvement when GET was added to SMC). The absence of actigraphy monitoring during the trial means that a truly objective measure of changes in physical activity was not included, but the six-minute walking distance test demonstrated a modest average improvement in physical disability when GET was added to SMC [5]. For the PACE trial, GET was designed to treat and ‘‘reverse’’ maladaptive avoidant behaviour, exercise intolerance and deconditioning which, it was hypothesised, cause or propagate
Address for correspondence: Robert Courtney. E-mail: information785@ gmail.com
CFS [6,7]. White et al. concluded: ‘‘Our finding that studied treatments were only moderately effective also suggests research into more effective treatments is needed’’ [5]. Given the disappointing results of the trial, the tested hypotheses (e.g. deconditioning etc.) were found wanting and suggest that impairments in CFS/ME are largely due to a different mechanism.
Declaration of interest The author reports no declaration of interest.
References 1. Gladwell PW, Pheby D, Rodriguez T, Poland F. Use of an online survey to explore positive and negative outcomes of rehabilitation for people with CFS/ME. Disabil Rehabil 2014;36:387–94. 2. Kindlon T. Reporting of harms associated with graded exercise therapy and cognitive behavioural therapy in myalgic encephalomyelitis/chronic fatigue syndrome. Bull IACFS/ME 2011;19: 59–111. 3. Edmonds M, McGuire H, Price J. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev 2004:CD003200. 4. McCrone P, Sharpe M, Chalder T, et al. Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis. PLoS One 2012;7:e40808. 5. White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011;377:823–36. 6. Bavinton J, Darbishire L, White PD; On behalf of the PACE trial management group. PACE manual for therapists: graded exercise therapy for CFS/ME. Final Trial Version Version 7. [Internet] PACE Trial; 2011. Available from: http://www.pacetrial.org/docs/gettherapist-manual.pdf [last accessed 10 Sep 2013]. 7. White PD, Sharpe MC, Chalder T, et al. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol 2007;7:6.
Copyright of Disability & Rehabilitation is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
