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Graded activity therapy
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'''Graded Activity Therapy''' or '''GAT''' is an alternative name for the controversial treatment '''[[graded exercise therapy|Graded Exercise Therapy]]''' (GET).<ref name="SharpeCampling">{{Cite book | title = Chronic Fatigue Syndrome | pages = 157|isbn=978-0-19-157971-4|edition=|volume=|language=en|title-link=| url = https://books.google.co.uk/books?id=DTefP_zDgyQC&pg=PT157&lpg=PT157&dq=%22graded+activity+therapy%22|access-date= | date = 2008-07-02| publisher = OUP Oxford | last = Campling | first = Frankie | authorlink = | last2 = Sharpe | first2 = Michael | authorlink2 = Michael Sharpe|veditors=|others=|doi=|oclc=|quote=GET is similar in many ways to CBT, but it concentrates more on changing coping behaviour rather than thinking. It might be better called graded activity therapy.|archive-url=|archive-date=|location=|editor-last = }}</ref><ref name="southtees2018">{{Cite web | url = https://www.southtees.nhs.uk/content/uploads/Session-1-full-updated-summer-2018-1.pdf | date = 2018 | website = South Tees Hospitals NHS Foundation | title = Group Rehabilitation Programme for people with CFS / ME. SESSION 1 | last = South Tees Specialist CFS/ME Service|at=Slide 17|access-date=2021-11-03|quote=GRADED EXERCISE THERAPY = GRADED ACTIVITY THERAPY}}</ref> '''Graded Activity Management (GAM)''' is another term used interchangeably with Graded Activity Therapy and Graded Exercise Therapy.<ref name="elft">{{Cite web | url = https://www.elft.nhs.uk/service/419/Bedfordshire-Chronic-Fatigue-Service | title = ELFT - Services - Bedfordshire Chronic Fatigue Service | last = | first = | authorlink = | date = 2021-10-30 | website = East London NHS|archive-url=|archive-date=|url-status=|access-date=2021-11-03|quote=NICE recommended Cognitive Behaviour Therapy (CBT) and Graded Activity Management (GAM)}}</ref> Graded Activity Therapy is defined in several different ways: * As identical to [[graded exercise therapy]],<ref name="SharpeCampling" /><ref name="southtees2018" /> or * As the same approach as graded exercise therapy but including [[cognitive dysfunction|cognitive / mental activity]] as well as physical activity<ref name="Cheshire2020">{{Cite journal | last = Cheshire | first = Anna | last2 = Ridge | first2 = Damien | last3 = Clark | first3 = Lucy | last4 = White | first4 = Peter | date = 2020-01-30 | title = Guided graded Exercise Self-help for chronic fatigue syndrome: patient experiences and perceptions| url = https://doi.org/10.1080/09638288.2018.1499822|journal=Disability and Rehabilitation|volume=42|issue=3 | pages = 368–377|doi=10.1080/09638288.2018.1499822|issn=0963-8288|pmid=30325677}}</ref><ref name="srft">{{Cite web | url = https://www.srft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=56453&type=full&servicetype=Inline | date = 2018 | title = Chronic Fatigue Syndrome (CFS)/ Myalgic Encephalopathy (ME) Management Programme|website=Salford Royal NHS Foundation Trust | last = |access-date=2021-11-03|quote=Scheduling Rest and Activity<br />The aim of cognitive-behaviour and graded activity therapy is not simply to be more active, but to make activity and rest consistent, rather than symptom dependent. By doing this you will be able to gradually increase your ability to carry out everyday activities while slowly cutting down on excessive rest.}}</ref> {{See also|Graded exercise therapy}} ==Theory == Graded activity therapy uses a '''graded''' approach, meaning continual goals involving increases in physical or cognitive activities regardless of the degree of symptoms or illness caused.<ref name="srft" /> The aim it to continue increase until full health is achieved, with CFS/ME assumed to be "curable" [[medically unexplained symptoms]] despite the known [[List of abnormal findings in chronic fatigue syndrome and myalgic encephalomyelitis|abnormal findings]] in ME/CFS patients. Under this graded approach there is no consideration for patients with a deteriorating course of ME/CFS, or of patients who do not improve. Patients are told to "push through" and ignore their symptoms. In [[cognitive behavioral therapy]] (CBT) patients are told their symptoms are not a sign of illness and to avoid "symptom focusing" but not to avoid "exercise and activity". Patients assumed to have abnormal [[illness beliefs]] in both CBT and GAT/GET, despite significant evidence disputing this.<ref name="Geraghty2019" /> This approach is known as the [[biopsychosocial model]] for ME/CFS, and is the justification for the use of both [[cognitive behavioral therapy]] and [[graded exercise therapy|graded activity/exercise therapy]] in [[ME/CFS]], which assumes no disease process is present and that symptoms are the result of inactivity, patient behaviors such as resting too much, and other factors claimed to [[The 3Ps model|"perpetuate"]] the illness.<ref name="Geraghty2019">{{Cite journal | last = Geraghty | first = Keith | authorlink = Keith Geraghty | last2 = Jason | first2 = Leonard | authorlink2 = Leonard Jason | last3 = Sunnquist | first3 = Madison | authorlink3 = Madison Sunnquist | last4 = Tuller | first4 = David | authorlink4 = David Tuller | last5 = Blease | first5 = Charlotte | authorlink5 = Charlotte Blease | last6 = Adeniji | first6 = Charles | authorlink6 = Charles Adeniji | date = Jan 1, 2019 | title = The ‘cognitive behavioural model’ of chronic fatigue syndrome: Critique of a flawed model| url = https://doi.org/10.1177/2055102919838907|journal=Health Psychology Open|language=en|volume=6|issue=1 | pages = 2055102919838907|doi=10.1177/2055102919838907|issn=2055-1029|quote=|via=}}</ref><ref name="Geraghty2018">{{Cite journal | last = Geraghty | first = Keith J. | authorlink =Keith Geraghty | authorlink2 =Charlotte Blease | last2 = Blease | first2 = Charlotte | date = 2018-06-21 | title = Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter |url =https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1481149?scroll=top&needAccess=true&journalCode=idre20&|journal=Disability and Rehabilitation|language=en | pages = 1–10|doi=10.1080/09638288.2018.1481149|issn=0963-8288}}</ref><ref name="Geraghty2016">{{Cite journal | last = Geraghty | first = Keith J. | last2 = Esmail | first2 = Aneez | authorlink2 = Esmail Aneez | authorlink =Keith Geraghty | date = 2016-08-01 | title = Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?| url = https://bjgp.org/content/66/649/437|journal=Br J Gen Pract|language=en|volume=66|issue=649 | pages = 437–438|doi=10.3399/bjgp16X686473|issn=0960-1643|pmid=27481982}}</ref><ref name="Parliament">{{Cite web | url = https://hansard.parliament.uk/commons/2018-02-20/debates/990746C7-9010-4566-940D-249F5026FF73/PACETrialPeopleWithME | title = PACE Trial: People with ME - Hansard | last = | first = | date = Feb 20, 2018 | website = hansard.parliament.uk|language=en|archive-url=|archive-date=|url-status=|access-date=2018-10-29|edition=Volume 636}}</ref><ref name="IIMER">{{Cite web | url = http://www.investinme.org/Documents/Fact%20Sheets/Invest%20in%20ME%20Research%20-%20Flaws%20in%20BPS%20Theory%20for%20ME%20Fact%20Sheet.pdf | title=Notes on the Ineffectiveness of the Biopsychosocial Model for Treating Myalgic Encephalomyelitis | last = Invest in ME Research | authorlink = Invest in ME Research | first = | date = |website=|archive-url=|archive-date=|url-status=|access-date= October 30, 2018}}</ref><ref name="GET-harms">{{Cite web | url = http://iacfsme.org/PDFS/Reporting-of-Harms-Associated-with-GET-and-CBT-in.aspx | title = Bulletin of the IACFS/ME 59 Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome | last = Kindlon | first = Tom | authorlink = Tom Kindlon | date = |website=IACFSME|archive-url=|archive-date=|access-date=}}</ref> ==PACE trial== The controversial PACE trial was the largest ever trial of graded exercise therapy, after a Freedom of Information Act request was granted in 2016, the full but anonymised data from the PACE trial patients was published, showing that graded exercise therapy did not result in clinically significant improvements in ME/CFS patients.<ref name="wilshire2018">{{Cite journal | last = Wilshire | first = Carolyn E. | authorlink = Carolyn Wilshire | last2 = Kindlon | first2 = Tom | authorlink2 = Tom Kindlon | last3 = Courtney | first3 = Robert | authorlink3 = Robert Courtney | last4 = Matthees | first4 = Alem | authorlink4 = Alem Matthees | last5 = Tuller | first5 = David | authorlink5 = David Tuller | last6 = Geraghty | first6 = Keith | authorlink6 = Keith Geraghty | last7 = Levin | first7 = Bruce | authorlink7 = Bruce Levin | date = 2018-03-22 | title = Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT| url = https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3|journal=BMC Psychology|language=en|volume=6|issue=1 | pages = |doi=10.1186/s40359-018-0218-3|issn=2050-7283|pmc=5863477|pmid=29562932|quote=|via=}}</ref><ref name="wilshire2016">{{Cite journal | last = Wilshire | first = Carolyn | last2 = Kindlon | first2 = Tom | last3 = Matthees | first3 = Alem | last4 = McGrath | first4 = Simon | date = 2016-12-14 | title = Can patients with chronic fatigue syndrome really recover after graded exercise or cognitive behavioural therapy? A critical commentary and preliminary re-analysis of the PACE trial| url = http://www.tandfonline.com/doi/full/10.1080/21641846.2017.1259724|journal = Fatigue: Biomedicine, Health & Behavior |language=en|volume=5|issue=1 | pages = 43–56|doi=10.1080/21641846.2017.1259724|issn=2164-1846}}</ref> Graded Activity Therapy is considered identical or nearly identical to graded exercise therapy by PACE trial authors [[Peter White]], [[Michael Sharpe]], [[Lucy Clark]], and other promoters of the [[Biopsychosocial model]] of ME/CFS, a model and treatment approaches now abandoned by the [[Centers for Disease Control|CDC]] in the [[United States]],<ref name="CDC-IOM-SEIDcriteria">{{Cite web | url = https://www.cdc.gov/me-cfs/healthcare-providers/diagnosis/iom-2015-diagnostic-criteria.html | title = IOM 2015 Diagnostic Criteria {{!}} Myalgic Encephalomyelitis/Chronic Fatigue Syndrome|website=[[Centers for Disease Control and Prevention]] | date = Jan 27, 2021|access-date = 2021-02-25}}</ref><ref name="CDCsymptoms">{{Cite web | url = https://www.cdc.gov/me-cfs/symptoms-diagnosis/symptoms.html | title = Symptoms {{!}} Myalgic Encephalomyelitis/Chronic Fatigue Syndrome|website=[[Centers for Disease Control and Prevention]] | date = Jan 27, 2021|access-date = 2021-02-25}}</ref> the Dutch Health Council in the [[Netherlands]],<ref name="Twisk, 20180516">{{Cite journal | last1 = Twisk | first1 = Frank | authorlink1 = Frank Twisk| title = Dutch Health Council advisory report on Myalgic Encephalomyelitis and Chronic Fatigue Syndrome: Taking the wrong turn | journal = [[Diagnostics]] | volume = 8 | issue = 2 | date = 2018 | doi = 10.3390/diagnostics8020034}}</ref> and by NICE and the NHS in [[England]] and [[Wales]].<ref name="ng206">{{Cite web | url = https://www.nice.org.uk/guidance/ng206 | title = Myalgic Encephalomyelitis (or Encephalopathy)/Chronic Fatigue Syndrome:diagnosis and management. NICE guideline. | last = NICE Guideline Development Group | first = | authorlink = | publisher = [[National Institute for Health and Care Excellence]] | date = 2021-10-29}}</ref> ==NICE guidelines 2021== The [[NICE guidelines]] update in 2021 changed the advice about graded exercise therapy (which had been recommended since 2007) to state that it was no longer recommended due to harms.<ref name="ng206" /><ref name="OxfordBrookesSurvey">{{Cite web | url = https://www.meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Final-Consolidated-Report-03.04.19.pdf | title =Evaluation of a survey exploring the experiences of adults and children with ME/CFS who have participated in CBT and GET interventional programmes. FINAL REPORT | last = Oxford Clinical Allied Technology and Trials Services Unit (OxCATTS)|location=Oxford Brookes University | date = Feb 27, 2019}}</ref> Days after the NICE guidelines update in 2021, some [[chronic fatigue syndrome]] clinics in the [[United Kingdom]] had already renamed their GET service documentation without making any other changes, leaving erroneous claims such as that Graded Activity Management was a NICE recommended therapy.<ref name="elft" /> Some CFS/ME clinics renamed their services prior to the final publication of the NICE guidelines, or chose different names for their graded exercise/activity programs years before.<ref name="srft" /> ==Criticisms== Criticisms of graded activity therapy are the same as those of graded exercise therapy, and research about the harms of graded exercise therapy also combined the alternative name of graded activity therapy.<ref name="IACFSME-harms">{{Cite web | url = http://iacfsme.org/PDFS/Reporting-of-Harms-Associated-with-GET-and-CBT-in.aspx | title = Bulletin of the IACFS/ME 59 Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome | last = Kindlon | first = Tom | authorlink = Tom Kindlon|website=IACFSME|archive-url=|archive-date=|access-date=}}</ref><ref name="Kindlon">https://www.tandfonline.com/doi/abs/10.3109/09638288.2013.797508</ref><ref name="Nodecisions">{{Cite web | url = http://www.meassociation.org.uk/wp-content/uploads/2015-ME-Association-Illness-Management-Report-No-decisions-about-me-without-me-30.05.15.pdf | title=ME/CFS Illness Management Survey Results - “No decisions about me without me” Part 1 | last = | first = | date = May 2015 | website = meassociation.org| publisher = ME Association|archive-url=|archive-date=|access-date=}}</ref><ref name="OxfordBrookesSurvey" /> {{See also|1=Graded exercise therapy#Criticism|2=Graded exercise therapy criticisms}} ==See also == *[[Exercise]] *[[Biopsychosocial model]] *[[Graded exercise therapy]] *[[Cognitive behavioral therapy]] *[[Sophia Mirza]] *[[Merryn Crofts]] *[[Wessely school]] ==References == {{Reflist}} [[Category:Psychological paradigm]] [[Category:Potential treatments]] [[Category:Psychological and behavioral therapies]] [[Category:Exercise treatments]]
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