Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis harming patients?

Opinion:

In April 2024, The Royal Australian College of General Practitioners (RACGP) Handbook of Non-Drug Interventions (HANDI)committee published a guideline: Incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis.1 The HANDI committee claims to recommend interventions that are based on ‘solid evidence’.2 But is this always the case?

An evaluation under the AGREE II instrument for assessing guidelines scored the RACGP guideline at only 2% for rigour of development.3 Alarmingly, the guideline provides no evidence of a systematic review of the literature, nor an analysis of the strengths and limitations of the three cited papers: the PACE trial; the Cochrane review, Exercise therapy for chronic fatigue syndrome; and Fawzy et al’s systematic review of treatments for post-acute COVID-19 syndrome [PACS]).1,4,5,6 Indeed, the PACE trial has been heavily criticised for outcome switching and bias.7–9 If the PACE trial had adhered to the original definition of recovery laid out at the beginning of the study, only 4% of graded exercise therapy participants would have been classified as recovered, and the effect would not have been statistically significant.9 After participants had completed therapy, the study’s authors weakened the definition of recovery to encompass values that fall far below healthy norms. In fact, many ‘recovered’ participants were still sick enough to meet the entry requirements to the study.8 Worse, some participants were classified as recovered or improved before undertaking any treatment.10

Read the rest of this article HERE>>

Source: Jacqueline Stallard Stephan Praet Sandeep Gupta Angela Smith. Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis harming patients? AJGP, Viewpoint​
Volume 55, Issue 3, March 2026. https://www1.racgp.org.au/ajgp/2026/march/is-the-racgp-handi-recommendation-of-incremental-p (Full text)

The risk of blaming patients for their lack of recovery

Dear Editor,

In their article on the management of patients with severe myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), Miller et al. propose a biopsychosocial model in which “a gradual, controlled approach to increasing activity is an important part of rehabilitation.” This approach, however, is far from new and has been tested in randomized trials with limited success.

The PACE study, for example, examined fourteen sessions of cognitive behaviour therapy (CBT) or graded exercise therapy (GET), each combined with specialist medical care. Treatment aimed to help ME/CFS patients gradually resume physical activities, address unhelpful cognitions, and reverse deconditioning. Recovery rates for GET and CBT were low and did not differ significantly from the control group, with rates of 4%, 7%, and 3%, respectively, as defined by the study’s pre-registered recovery criteria. [1] Employment and fitness data also showed no clinically significant improvement. [2]

Read the full letter by Michiel Tack here: https://www.bmj.com/content/389/bmj.r977/rr-3

The PACE Trial’s GET Manual for Therapists Exposes the Fixed Incremental Nature of Graded Exercise Therapy for ME/CFS

Abstract:

The British National Institute for Health and Care Excellence (NICE) published its updated guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in October 2021. NICE concluded, after an extensive review of the literature, that graded exercise therapy (GET) is harmful and should not be used, and that cognitive behavioural therapy (CBT) is only an adjunctive and not a curative treatment. An article by White et al., which is written by 51 researchers, claims that there are eight anomalies in the review process and the interpretation of the evidence by NICE. In this article, we reviewed the evidence they used to support their claims.

Their three most important claims are that NICE redefined the disease, that CBT and GET are effective, and that fixed incremental increases are not part of GET. However, our analysis shows that the disease was not redefined by NICE. Instead, it was redefined in the 1990s by a group of doctors, including a number of authors of White et al., when they erased the main characteristic of the disease (an abnormally delayed muscle recovery after trivial exertion, which, over the years, has evolved into post-exertional malaise) and replaced it with chronic disabling severe fatigue. Their own studies show that CBT and GET do not lead to a substantial improvement of the quality-of-life scores or a reduction in CFS symptom count, nor do they lead to objective improvement.

Also, both treatments have a negative instead of a positive effect on work and disability status. Moreover, a recent systematic review, which included one of the authors of White et al., showed that ME/CFS patients remain severely disabled after treatment with CBT. Our analysis of, for example, the PACE trial’s GET manual for therapists exposes the fixed incremental nature of GET.

Why the authors are not aware of that is unclear because eight of them were involved in the PACE trial. Three of them were centre leaders and its principal investigators, four others were also centre leaders, and another one was one of the three independent safety assessors of the trial. Moreover, many of these eight authors wrote, or were involved in writing, this manual.

In conclusion, our analysis shows that the arguments that are used to claim that there are eight anomalies in the review process and the interpretation of the evidence by NICE are anomalous and highlight the absence of evidence for the claims that are made. Furthermore, our analysis not only exposes the fixed incremental nature of GET, but also of CBT for ME/CFS.

Source:Vink M, Partyka-Vink K. The PACE Trial’s GET Manual for Therapists Exposes the Fixed Incremental Nature of Graded Exercise Therapy for ME/CFS. Life (Basel). 2025 Apr 2;15(4):584. doi: 10.3390/life15040584. PMID: 40283139. https://www.mdpi.com/2075-1729/15/4/584 (Full text)

Lessons from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome for Long COVID Part 3: “Energy System First Aid” for People With Postexertional Symptom Exacerbation

In a previous post, we demonstrated that the symptoms and physiology of postexertional symptom exacerbation (PESE) are inconsistent with deconditioning. PESE worsens in response to exercise and demonstrates a variable clinical presentation. We will build a clinical rationale for energy system first aid as a place to start helping people with PESE.

Graded Exercise May Be Harmful to People With PESE

It is not surprising that patients with PESE frequently report worsening symptoms and function with exercise prescribed based on time and activity quotas,1 based on the physiological evidence. The United Kingdom’s Pacing, graded Activity, and Cognitive behaviour therapy, a randomized Evaluation (UK PACE) compared the clinical outcomes of specialist medical care, adaptive pacing, and graded exercise therapy (GET) in 641 people with idiopathic, disabling fatigue.9 In this study, GET was a quota-based progressive exercise program, where subjects incrementally increased exercise regardless of symptoms. PESE was not a specific recruitment criterion for this trial.8,9 The trial did not adhere to the published protocol, without appropriate justification. The raw data was independently reanalyzed according to the original protocol,10 Upon reanalysis, most symptomatic and functional outcome findings from the UK PACE trial did not reach thresholds for clinical relevance. Many ME/CFS experts contend the results of GET are marginal, probably not clinically relevant or beneficial.10

Despite the important concerns of the UK PACE trial, the trial continues to exert outsized influence on clinical guidelines.3 Some countries’ systems developed formal treatment pathways based on flawed results. Treatment pathways involving GET may have exposed an untold number of patients with ME/CFS worldwide to a GET program that, at best, is marginally effective, and at worst, may be harmful. Recent clinical guidelines for people with PESE, such as long COVID, no longer involve GET.6,7 These omissions reflect the ongoing re-evaluation of how clinical care should proceed for people with PESE, including people with long COVID. Implicit to this re-evaluation is a further reflection on the generally accepted idea that “movement is medicine” in a way that universally benefits clinical populations.

Read the full article HERE.

Source: Todd E. Davenport, Staci R. Stevens, Jared Stevens, Christopher R. Snell, J. Mark Van Ness. Lessons from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome for Long COVID Part 3: “Energy System First Aid” for People With Postexertional Symptom Exacerbation. JOSPT blog, Published online on February 16, 2022. https://doi.org/10.2519/jospt.blog.20220216 (Full text)

Rethinking the Standard of Care for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

For over two decades, the standard of care for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has been cognitive behavior therapy (CBT) and graded exercise therapy (GET). Both interventions had been recommended by the US Centers for Disease Control and the UK NICE guidelines. Behavioral intervention as the clinical standard was given a considerable boost by the 5 million–pound PACE trial, a large multi-arm randomized trial of CBT and GET launched in 2007. This British government–funded trial was intended to definitively answer whether such interventions were beneficial in ME/CFS. In their 2011 and 2013 publications, the PACE trial authors announced with widespread publicity that 22% of their patients had “recovered” and 59–61% had clinically improved across the CBT and GET interventions.

Read the rest of this article here.

Source: Friedberg, F., Sunnquist, M. & Nacul, L. J GEN INTERN MED (2019). https://doi.org/10.1007/s11606-019-05375-y https://link.springer.com/article/10.1007%2Fs11606-019-05375-y

Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy and graded exercise therapy for patients with myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review

Abstract:

Cognitive behavioural therapy and graded exercise therapy have been promoted as effective treatments for patients with myalgic encephalomyelitis/chronic fatigue syndrome. However, criticism on the scientific rigour of these studies has been raised. This review assessed the methodological quality of studies on the effectiveness of cognitive behavioural therapy and graded exercise therapy. The methodological quality of the 18 included studies was found to be relatively low, as bias was prominently found, affecting the main outcome measures of the studies (fatigue, physical functioning and functional impairment/status). Future research should focus on including more objective outcome measures in a well-defined patient population.

Source: Ahmed SA, Mewes JC, Vrijhoef H. Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy and graded exercise therapy for patients with myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review. J Health Psychol. 2019 May 10:1359105319847261. doi: 10.1177/1359105319847261. [Epub ahead of print] https://www.ncbi.nlm.nih.gov/pubmed/31072121

Response: Sharpe, Goldsmith and Chalder fail to restore confidence in the PACE trial findings

Abstract:

In a recent paper, we argued that the conclusions of the PACE trial of chronic fatigue syndrome are problematic because the pre-registered protocol was not adhered to. We showed that when the originally specific outcomes and analyses are used, the evidence for the effectiveness of CBT and graded exercise therapy is weak.

In a companion paper to this article, Sharpe, Goldsmith and Chalder dismiss the concerns we raised and maintain that the original conclusions are robust. In this rejoinder, we clarify one misconception in their commentary, and address seven additional arguments they raise in defence of their conclusions.

We conclude that none of these arguments is sufficient to justify digressing from the pre-registered trial protocol. Specifically, the PACE authors view the trial protocol as a preliminary plan, subject to honing and improvement as time progresses, whereas we view it as a contract that should not be broken except in extremely unusual circumstances. While the arguments presented by Sharpe and colleagues inspire some interesting reflections on the scientific process, they fail to restore confidence in the PACE trial’s conclusions.

Source: Carolyn E. Wilshire and Tom Kindlon. Response: Sharpe, Goldsmith and Chalder fail to restore confidence in the PACE trial findings. BMC Psychology20197:19
https://doi.org/10.1186/s40359-019-0296-x© The Author(s). 2019 https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-019-0296-x (Full article)

MPs demand more biomedical research for cruel ‘death sentence’ disease

Press Release: ME Association, June 21, 2018. Less than £1 is spent each year on people suffering from the devastating invisible illness M.E. (myalgic encephalomyelitis), a condition which leaves tens of thousands bedbound, housebound and unable to work.

Parliament heard in a landmark three-hour debate of the chronic lack of funding for medical research and how many doctors still don’t know how to diagnose or manage the condition.

End to controversial therapies and to stigma

Politicians said that controversial psychotherapy and exercise therapies recommended by the NHS after a flawed medical trial must stop NOW – because they are making patients worse.

And they called for an end to the stigma and myths surrounding M.E., which at worst, leaves sufferers to endure a tortuous existence.

Westminster Hall was told how people with M.E. are six times more likely to commit suicide.

Carol Monaghan (SNP Glasgow North West) told how ME costs the UK £3.3bn per year.

She said: “Despite the number of people affected and the devastating effect of the disease on sufferers and their families, it is very much a hidden illness, which is characterised by some as ‘yuppie flu’ and misunderstood by doctors, the public and politicians alike.”

M.E. tragedies

Westminster Hall heard of the tragic case of 21-year-old Merryn Crofts, who last month had M.E. listed as the cause of her death at inquest, and how ME Association fundraising manager, Helen Hyland, broke the news of her husband’s suicide to her children.

Yet Ms Monaghan added: “Some people consider M.E. to be a psychological condition, despite the fact that people with M.E. are not allowed to be blood or organ donors.

“Unfortunately, those who hold such beliefs often are in influential positions and have a blinkered view of the condition.

“I wonder what they have to fear from proper biomedical research into M.E. If such research showed they were correct, their views would be vindicated. However, if it threw up new information that had an impact on M.E. treatment and care, as medical professionals they should surely support that.”

The discredited PACE trial

Ms Monaghan drew particular attention to the PACE trial results in 2011, that examined graded exercise therapy (GET) and cognitive behaviour therapy (CBT).

The researchers claimed the results demonstrated both treatments were ‘moderately’ effective and led to recovery in over a fifth of patients.

But the trial has since faced intense criticism, and not only from patients in the UK. Clinicians, researchers, as well as charities, like the ME Association, have all expressed concern about how the results were obtained, analysed and presented.

Parliament has previously heard claims that the PACE trial data was deliberately flawed to “remove people from long-term benefits and reduce the welfare bill”. The PACE trial endorsement of GET and CBT helped form the basis of the NICE clinical guideline – which is now being reviewed.

PACE has had a wide-reaching influence

Ms Monaghan said one of the key authors behind the PACE trial, Professor Michael Sharpe, admitted that some involved in the trial had worked for insurance companies.

She said: “The PACE trial, which recommended CBT and GET, influences how health insurers and the DWP make their decisions.

“Insurance companies refuse to pay out unless a programme of GET has been undertaken, and many people who apply for benefits are told that they must carry out GET—or, indeed, that they appear well enough to work.

“PACE is unique in UK medical history, in that it was part-funded by the DWP.

“The links of some of its ​main authors to health insurance companies are troubling. One of those authors, Professor Michael Sharpe, states in his briefing for the debate:

“Several of the investigators had done small amounts of independent consultancy for insurance companies, but this was not relevant to the trial. The insurance companies played no part in the trial.”

“I will leave hon. Members to make up their own minds about that.”

Westminster Hall was told how the U.S. Center for Disease Control (CDC) and the Dutch Health Council have both abandoned GET as a treatment.

Ms Monaghan added: “If those countries acknowledge the flaws of GET, why are ME sufferers in the UK having to fight so hard for similar acknowledgement? The ME community hopes that GET will not feature in the NICE guidelines for ME treatment after they are revised.”

‘Unbecoming’ behaviour?

“Interestingly, Professor Sharpe, one of the authors of the PACE trial whom I already mentioned, emailed me this week and told me that my behaviour is “unbecoming ​of an MP”.

“I say to Professor Sharpe that if listening to my constituents, investigating their concerns and taking action as a result is “unbecoming”, I stand guilty.

“If Members of Parliament are not willing to stand up for the most vulnerable in society, what hope do any of us have?”

Ministerial response

Minister for Health and Social Care, Steve Brine, was asked how the Department for Health is supporting training for medical practitioners on ME care and treatment, and asked if he would support proper funding for medical research into the diagnosis and treatment of ME.

Mr Brine said the government invests £1.7bn each year into health research.

And stated that the National Institute for Health Research and the Medical Research Council would welcome “high-quality” research into “all aspects of ME… to make a scientific breakthrough”.

He described the need to find a breakthrough as a “matter of good Christian humanity” and promised to help increase the awareness of M.E. with GPs.

Read the full Ministerial response and Ms. Monaghan’s closing remarks HERE.

He reiterated that patients with M.E. symptoms should be referred to NHS specialist services – within six months for mild symptoms, three months for moderate symptoms and immediately for severe symptoms.

But Mr Brine admitted that access to services remained “a big and ongoing issue” and that the configuration of services was down to local commissioning groups.

He added that all schools must have arrangements in place to support, with flexibility, children with ME.

NICE guideline review

On the NICE guidelines, he said it was a “jolly good job” the position on M.E. is being updated but said it would be “wrong for ministers to interfere” with the process.

On benefits, Mr Brine said the “DWP recognises that ME is a real and disabling condition” and that every patient must be assessed on a individual basis.

He added: “When assessing claimants, healthcare professionals are expected to be mindful of the fact that many illnesses—including ME—produce symptoms that vary in intensity over time, and they are instructed not to base their opinion solely on the situation observed at the assessment.

“The DWP assures me that all healthcare professionals are required to read an evidence-based protocol on ME as part of their training, as well as engaging in a programme of continuing medical education that includes modules on the condition.”

‘A completely unacceptable situation’

The ME Association campaigns to make the UK a better place for people with M.E. A spokesman said: “A three-hour parliamentary debate on M.E. is not before time. We are grateful to Carol Monaghan for securing the debate, to those MPs who took part, and to ME Association members for engaging with their parliamentary representatives ahead of the debate.

“Despite being recognised by the World Health Organisation as a neurological disease – and an earlier report to the Chief Medical Officer calling for more research and a network of hospital-based clinics – many doctors still don’t know how to diagnose and manage M.E. and lack of biomedical research means that we still don’t have any effective forms of treatment.

“This is a completely unacceptable situation for a disease that is twice as common as multiple sclerosis and where a new report has estimated that M.E. is costing the UK economy billions in lost taxes, and through healthcare and benefit expenditure.”

Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT

Abstract:

Background: The PACE trial was a well-powered randomised trial designed to examine the efficacy of graded exercise therapy (GET) and cognitive behavioural therapy (CBT) for chronic fatigue syndrome. Reports concluded that both treatments were moderately effective, each leading to recovery in over a fifth of patients. However, the reported analyses did not consistently follow the procedures set out in the published protocol, and it is unclear whether the conclusions are fully justified by the evidence.

Methods: Here, we present results based on the original protocol-specified procedures. Data from a recent Freedom of Information request enabled us to closely approximate these procedures. We also evaluate the conclusions from the trial as a whole.

Results: On the original protocol-specified primary outcome measure – overall improvement rates – there was a significant effect of treatment group. However, the groups receiving CBT or GET did not significantly outperform the Control group after correcting for the number of comparisons specified in the trial protocol. Also, rates of recovery were consistently low and not significantly different across treatment groups. Finally, on secondary measures, significant effects were almost entirely confined to self-report measures. These effects did not endure beyond two years.

Conclusions: These findings raise serious concerns about the robustness of the claims made about the efficacy of CBT and GET. The modest treatment effects obtained on self-report measures in the PACE trial do not exceed what could be reasonably accounted for by participant reporting biases.

Source: Carolyn E. Wilshire, Tom Kindlon, Robert Courtney, Alem Matthees, David Tuller, Keith Geraghty and Bruce Levin. Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT. BMC PsychologyBMC series. Received: 29 May 2017; Accepted: 22 February 2018; Published: 22 March 2018.  https://doi.org/10.1186/s40359-018-0218-3 (Full article) © The Author(s) 2018.

Time to Reject the PACE Study

Abstract:

The PACE trial investigated the efficacy of graded exercise therapy and cognitive behavioral therapy for ME/CFS. The design and the implementation of the study were flawed, and the conclusions are contradicted by the data. It is time to reject the study.

https://www.researchgate.net/publication/320101462_Time_to_Reject_the_PACE_Study [Full article].

This is a translation of an article that was published in slightly shortened form in Läkartidningen, Stockholm, Sweden, on 28 September 2017. http://www.lakartidningen.se/

Link to the shortened article in Swedish: http://www.lakartidningen.se/Opinion/De-batt/2017/09/Dags-att-forkasta-PACE-studien/

Source: Helmfrid S, Edsberg J. Dags att förkasta PACE-studien. Lakartid-ningen. 2017;114:ETLE.