Graded exercise therapy: Difference between revisions

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[[File:Increasingvalueschart-gradedexercise.png|thumb|200x200px]]
[[File:Increasingvalueschart-gradedexercise.png|thumb|200x200px]]
'''Graded exercise therapy''' (GET) is a form of physical therapy for the treatment of [[chronic fatigue syndrome]] (CFS) where physical activity is gradually increased over time, regardless of how the patient is feeling and ignoring any increased symptoms or new symptoms.  GET was offered as a primary treatment for [[ME/CFS]] to [[UK]] patients by the [[National Health Service]] (NHS), as specified in the [[NICE guidelines]] from 2007-2021, but the GET recommendation was removed by the 2021 [[NICE guidelines]] update because of high rates of harm.<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> The use of Graded Exercise Therapy as a treatment is based on the disputed [[deconditioning]] hypothesis, and the highly controversial [[biopsychosocial model]] (BPS) of ME/CFS.<ref name=":0" />
'''Graded exercise therapy''' (GET) is a form of physical therapy for the treatment of [[chronic fatigue syndrome]] (CFS) where physical activity is gradually increased over time, regardless of how the patient is feeling and ignoring any increased symptoms or new symptoms.  GET was offered as a primary treatment for [[ME/CFS]] to [[UK]] patients by the [[National Health Service]] (NHS), as specified in the [[NICE guidelines]] from 2007-2021, but the GET recommendation was removed by the 2021 [[NICE guidelines]] update because of high rates of harm.<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> The use of Graded Exercise Therapy as a treatment is based on the disputed [[deconditioning]] hypothesis, and the highly controversial [[biopsychosocial model]] (BPS) of ME/CFS.<ref name=":0" />


Alternative names used for graded exercise therapy include [[graded activity management|'''Graded Activity Management''']] (GAM), and '''Graded Activity Therapy''' (GAT).<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|author-link=|last2=Sharpe|first2=Michael|author-link2=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><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>
Alternative names used for graded exercise therapy include [[graded activity management|'''Graded Activity Management''']] (GAM), and '''Graded Activity Therapy''' (GAT).<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><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:
Graded Activity Therapy is defined in several different ways:
* As identical to graded exercise therapy,<ref name="SharpeCampling" /><ref name="southtees2018" /> or
* As identical to graded exercise therapy,<ref name="SharpeCampling" /><ref name="southtees2018" /> or
* As the same approach 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>
* As the same approach 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>


== Evidence ==
== Evidence ==
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Clinical trials have resulted in mixed results.<ref name=":0" /><ref name=":1" /><ref name=":5" /> Surveys of patients conducted by patient charities have universally found Graded Exercise Therapy to be harmful, although a minority of patients found it helped them or simply ineffective.<ref name=":2" /><ref name=":3" /> A number of severely ill patients have reported that starting Graded Exercise Therapy with moderate symptoms cause a severe escalation of symptoms, leaving them permanently worse. Two highly influential peer-reviewed articles often used to support the use of Graded Exercise Therapy, the [[Cochrane]] review and the [[PACE trial]], have had widescale calls for retraction based on criticism of the scientific method and standards used.<ref name=":5" />
Clinical trials have resulted in mixed results.<ref name=":0" /><ref name=":1" /><ref name=":5" /> Surveys of patients conducted by patient charities have universally found Graded Exercise Therapy to be harmful, although a minority of patients found it helped them or simply ineffective.<ref name=":2" /><ref name=":3" /> A number of severely ill patients have reported that starting Graded Exercise Therapy with moderate symptoms cause a severe escalation of symptoms, leaving them permanently worse. Two highly influential peer-reviewed articles often used to support the use of Graded Exercise Therapy, the [[Cochrane]] review and the [[PACE trial]], have had widescale calls for retraction based on criticism of the scientific method and standards used.<ref name=":5" />


[[Robin Brown]], a British doctor with ME/CFS has created petition that many thousands have signed calling for GET and related [[Cognitive behavioral therapy|CBT]] to be removed from the UK treatment guidelines immediately.<ref>{{Cite web|url=https://www.change.org/p/nice-stop-harming-me-cfs-patients-take-cbt-get-out-of-me-cfs-guidelines-now|title=NICE stop harming ME/CFS patients - Take CBT and GET out of the CFS guidelines NOW! {{!}} Sign the Petition|last=Brown|first=Robin|authorlink=Robin Brown|date=|website=Change.org|language=en-GB|archive-url=|archive-date=|access-date=2018-11-13}}</ref>
[[Robin Brown]], a British doctor with ME/CFS has created petition that many thousands have signed calling for GET and related [[Cognitive behavioral therapy|CBT]] to be removed from the UK treatment guidelines immediately.<ref>{{Cite web | url=https://www.change.org/p/nice-stop-harming-me-cfs-patients-take-cbt-get-out-of-me-cfs-guidelines-now | title = NICE stop harming ME/CFS patients - Take CBT and GET out of the CFS guidelines NOW! {{!}} Sign the Petition | last = Brown | first = Robin | authorlink = Robin Brown | date = |website=Change.org|language=en-GB|archive-url=|archive-date=|access-date=2018-11-13}}</ref>


=== Physical fitness unchanged ===
=== Physical fitness unchanged ===
A number of studies by proponents of GET have found that it did not improve fitness, when self-rated perception of fatigue did improve after GET, no improvements in exercise capacity were statistically significant.<ref name=":0" /><ref>{{Cite journal|last=Moss-Morris|first=Rona|author-link=Rona Moss-Morris|last2=Sharon|first2=Cynthia|author-link2=Cynthia Sharon|last3=Tobin|first3=Roseanne|author-link3=Roseanne Tobin|last4=Baldi|first4=James C.|author-link4=James Baldi|author-link5=|date=Mar 2005|title=A Randomized Controlled Graded Exercise Trial for Chronic Fatigue Syndrome: Outcomes and Mechanisms of Change|url=https://journals.sagepub.com/doi/abs/10.1177/1359105305049774|journal=Journal of Health Psychology|language=en|volume=10|issue=2|pages=245–259|doi=10.1177/1359105305049774|issn=1359-1053|quote=|via=}}</ref><ref name=":4" /> The controversial PACE trial's 6 minute walk test results showed those successfully completing GET were unable to walk as far as older patients awaiting a lung transplant or those with heart failure; data that was omitted from the original trial report.<ref name=":4" />
A number of studies by proponents of GET have found that it did not improve fitness, when self-rated perception of fatigue did improve after GET, no improvements in exercise capacity were statistically significant.<ref name=":0" /><ref>{{Cite journal | last = Moss-Morris | first = Rona | authorlink = Rona Moss-Morris | last2 = Sharon | first2 = Cynthia | authorlink2 = Cynthia Sharon | last3 = Tobin | first3 = Roseanne | authorlink3 = Roseanne Tobin | last4 = Baldi | first4 = James C. | authorlink4 = James Baldi | authorlink5 = | date = Mar 2005 | title = A Randomized Controlled Graded Exercise Trial for Chronic Fatigue Syndrome: Outcomes and Mechanisms of Change| url = https://journals.sagepub.com/doi/abs/10.1177/1359105305049774|journal=Journal of Health Psychology|language=en|volume=10|issue=2 | pages = 245–259|doi=10.1177/1359105305049774|issn=1359-1053|quote=|via=}}</ref><ref name=":4" /> The controversial PACE trial's 6 minute walk test results showed those successfully completing GET were unable to walk as far as older patients awaiting a lung transplant or those with heart failure; data that was omitted from the original trial report.<ref name=":4" />


==Patient analysis of PACE results==
==Patient analysis of PACE results==
[[Graham McPhee]] and others created videos investigating the PACE trial data in relation to GET.<ref>{{Cite web|url=https://vimeo.com/21850334|title=PACEindividuals|website=Vimeo|language=en|access-date=2018-10-13}}</ref><ref>{{Cite web|url=https://vimeo.com/21852891|title=PACEgraph|website=Vimeo|language=en|access-date=2018-10-13}}</ref> Several re-analyses of the PACE trial results have been published since the detailed PACE trial data was released into the public domain.<ref name=":4" />  
[[Graham McPhee]] and others created videos investigating the PACE trial data in relation to GET.<ref>{{Cite web | url=https://vimeo.com/21850334 | title = PACEindividuals|website=Vimeo|language=en|access-date=2018-10-13}}</ref><ref>{{Cite web | url=https://vimeo.com/21852891 | title = PACEgraph|website=Vimeo|language=en|access-date=2018-10-13}}</ref> Several re-analyses of the PACE trial results have been published since the detailed PACE trial data was released into the public domain.<ref name=":4" />  


==Fear of exercise==
==Fear of exercise==
The [[PACE Trial Management Group|PACE trial investigators]] have stated that they believe a significant maintaining factor in the persistence of ME/CFS is fear of [[exercise]].<ref>{{Cite journal|last=Torjesen|first=Ingrid|date=2015-10-28|title=Tackling fear about exercise produces long term benefit in chronic fatigue syndrome|url=https://www.bmj.com/content/351/bmj.h5771|journal=BMJ|language=en|volume=351|pages=h5771|doi=10.1136/bmj.h5771|issn=1756-1833|pmid=26511755}}</ref> This claim has been criticized as unsupported by trial results.<ref>{{Cite journal|date=2018-10-13|title=Objective measures found a lack of improvement for CBT & GET in the PACE Trial: subjective improvements may simply represent response biases or placebo effects in this non-blinded trial|url=https://www.bmj.com/content/350/bmj.h227/rr-10|journal=The BMJ|language=en}}</ref> A study by [[Jo Nijs|Nijs]] et al. in 2004 concluded:
The [[PACE Trial Management Group|PACE trial investigators]] have stated that they believe a significant maintaining factor in the persistence of ME/CFS is fear of [[exercise]].<ref>{{Cite journal | last = Torjesen | first = Ingrid | date = 2015-10-28 | title = Tackling fear about exercise produces long term benefit in chronic fatigue syndrome| url = https://www.bmj.com/content/351/bmj.h5771|journal=BMJ|language=en|volume=351 | pages = h5771|doi=10.1136/bmj.h5771|issn=1756-1833|pmid=26511755}}</ref> This claim has been criticized as unsupported by trial results.<ref>{{Cite journal | date = 2018-10-13 | title = Objective measures found a lack of improvement for CBT & GET in the PACE Trial: subjective improvements may simply represent response biases or placebo effects in this non-blinded trial| url = https://www.bmj.com/content/350/bmj.h227/rr-10|journal=The BMJ|language=en}}</ref> A study by [[Jo Nijs|Nijs]] et al. in 2004 concluded:


{{Quote box|quote=These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with [[chronic fatigue syndrome |CFS]] who are experiencing widespread [[myalgia |muscle]] or [[arthralgia |joint pain]].|title=Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability|source=Jo Nij, Katrien Vanherberghen, William Duquet & Kenny De Meirleir (2004)}}
{{Quote box|quote=These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with [[chronic fatigue syndrome |CFS]] who are experiencing widespread [[myalgia |muscle]] or [[arthralgia |joint pain]]. | title = Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability|source=Jo Nij, Katrien Vanherberghen, William Duquet & Kenny De Meirleir (2004)}}


==Doctors who are patients with ME/CFS==
==Doctors who are patients with ME/CFS==
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==NICE's 2019 patient survey ==
==NICE's 2019 patient survey ==
An independent patient survey of UK patients was comissioned by [[NICE]] in 2019, as part of the [[NHS]] guideline review process.<ref name="OxBrookesSummary">{{Cite web|url= https://meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Executive-Summary-from-Forward-ME-03.04.19.pdf|type=pdf|date=2019-04-03|title=Forward-ME Executive Summary|website=ME Association|last=Forward-ME|author-link=Forward-ME}}</ref>
An independent patient survey of UK patients was comissioned by [[NICE]] in 2019, as part of the [[NHS]] guideline review process.<ref name="OxBrookesSummary">{{Cite web | url= https://meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Executive-Summary-from-Forward-ME-03.04.19.pdf | type=pdf | date = 2019-04-03 | title = Forward-ME Executive Summary|website=ME Association | last = Forward-ME | authorlink = Forward-ME}}</ref>


{| class="wikitable"
{| class="wikitable"
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== Articles explaining GET not appropriate for ME/CFS ==
== Articles explaining GET not appropriate for ME/CFS ==
* 2005, [http://stonebird.co.uk/GET.pdf Issues relating to Severe ME And Graded Exercise]<ref>{{Cite web|url=http://stonebird.co.uk/GET.pdf|title=Issues relating to Severe ME And Graded Exercise|last=Crowhurst|first=Greg|authorlink=Greg Crowhurst|date=Sep 3, 2005|website=Stonebird|archive-url=|archive-date=|access-date=}}</ref>
* 2005, [http://stonebird.co.uk/GET.pdf Issues relating to Severe ME And Graded Exercise]<ref>{{Cite web | url=http://stonebird.co.uk/GET.pdf | title=Issues relating to Severe ME And Graded Exercise | last = Crowhurst | first = Greg | authorlink=Greg Crowhurst | date = Sep 3, 2005 | website = Stonebird|archive-url=|archive-date=|access-date=}}</ref>
* 2016, [https://undark.org/article/chronic-fatigue-graded-exercise-pace/ Worse Than the Disease: A popular therapy for chronic fatigue syndrome made many patients worse. Adding insult to injury, research supporting it is now unraveling.]<ref name=":6" />
* 2016, [https://undark.org/article/chronic-fatigue-graded-exercise-pace/ Worse Than the Disease: A popular therapy for chronic fatigue syndrome made many patients worse. Adding insult to injury, research supporting it is now unraveling.]<ref name=":6" />
* 2017, [https://www.buzzfeed.com/camillamaxted/this-is-why-i-quit-exercise-therapy This is why I quit Exercise Therapy]<ref>{{Cite news|url=https://www.buzzfeed.com/camillamaxted/this-is-why-i-quit-exercise-therapy|title=This Is Why I Quit Exercise Therapy|last=Maxted|first=Camilla|date=Aug 6, 2017|work=BuzzFeed|access-date=2018-11-29|archive-url=|archive-date=|language=en|quote=|author-link=}}</ref>  
* 2017, [https://www.buzzfeed.com/camillamaxted/this-is-why-i-quit-exercise-therapy This is why I quit Exercise Therapy]<ref>{{Cite news | url=https://www.buzzfeed.com/camillamaxted/this-is-why-i-quit-exercise-therapy | title = This Is Why I Quit Exercise Therapy | last = Maxted | first = Camilla | date = Aug 6, 2017|work=BuzzFeed|access-date=2018-11-29|archive-url=|archive-date=|language=en|quote=}}</ref>  
* 2017, [http://journals.sagepub.com/doi/full/10.1177/1359105317697323 Do graded activity therapies cause harm in chronic fatigue syndrome?]<ref>{{Cite journal|last=Kindlon|first=Tom|date=2017-03-20|title=Do graded activity therapies cause harm in chronic fatigue syndrome?|url=http://journals.sagepub.com/doi/full/10.1177/1359105317697323|journal=Journal of Health Psychology|language=en|volume=22|issue=9|pages=1146–1154|doi=10.1177/1359105317697323|issn=1359-1053}}</ref>
* 2017, [http://journals.sagepub.com/doi/full/10.1177/1359105317697323 Do graded activity therapies cause harm in chronic fatigue syndrome?]<ref>{{Cite journal | last = Kindlon | first = Tom | date = 2017-03-20 | title = Do graded activity therapies cause harm in chronic fatigue syndrome?| url = http://journals.sagepub.com/doi/full/10.1177/1359105317697323|journal=Journal of Health Psychology|language=en|volume=22|issue=9 | pages = 1146–1154|doi=10.1177/1359105317697323|issn=1359-1053}}</ref>
*2018, [https://repository.uel.ac.uk/download/b9ef0ae9a8494102fe0bfface6eb12d5651bc78be4eda0401b72d1896cb16858/137216/2012_Goudsmit_etal_Pacing.doc Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document]<ref name="Goudsmit2018Pacing">{{Cite journal|last=Goudsmit|first=Ellen M.|author-link=Ellen Goudsmit|last2=Nijs|first2=Jo|author-link2=Jo Nijs|last3=Jason|first3=Leonard A.|author-link3=Leonard Jason|last4=Wallman|first4=Karen E.|author-link4=|date=2011-12-19|title=Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document|url=https://dx.org/10.3109/09638288.2011.635746|journal=Disability and Rehabilitation|volume=34|issue=13|pages=1140–1147|doi=10.3109/09638288.2011.635746|issn=0963-8288|pmc=|pmid=|access-date=|quote=|via=}}</ref>
*2018, [https://repository.uel.ac.uk/download/b9ef0ae9a8494102fe0bfface6eb12d5651bc78be4eda0401b72d1896cb16858/137216/2012_Goudsmit_etal_Pacing.doc Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document]<ref name="Goudsmit2018Pacing">{{Cite journal | last = Goudsmit | first = Ellen M. | authorlink = Ellen Goudsmit | last2 = Nijs | first2 = Jo | authorlink2 = Jo Nijs | last3 = Jason | first3 = Leonard A. | authorlink3 = Leonard Jason | last4 = Wallman | first4 = Karen E. | authorlink4 = | date = 2011-12-19 | title = Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document| url = https://dx.org/10.3109/09638288.2011.635746|journal=Disability and Rehabilitation|volume=34|issue=13 | pages = 1140–1147|doi=10.3109/09638288.2011.635746|issn=0963-8288|pmc=|pmid=|access-date=|quote=|via=}}</ref>
::''Describing graded exercise in comparison with symptom-contingent graded exercise therapy or pacing''
::''Describing graded exercise in comparison with symptom-contingent graded exercise therapy or pacing''
* 2019, [https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/ Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome]<ref name="Tack2019">{{Cite web|url=https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/|title=Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome|last=Michiel|first=Tack|authorlink=Michiel Tack|date=Jul 4, 2019|website=BMJ Medical Humanities Blog|language=en-US|archive-url=|archive-date=|access-date=2019-07-09}}</ref>
* 2019, [https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/ Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome]<ref name="Tack2019">{{Cite web | url=https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/ | title = Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome | last = Michiel | first = Tack | authorlink = Michiel Tack | date = Jul 4, 2019 | website = BMJ Medical Humanities Blog|language=en-US|archive-url=|archive-date=|access-date=2019-07-09}}</ref>


==Criticism==
==Criticism==
*2008, [https://meassociation.org.uk/2008/05/mea-position-on-graded-exercise-therapy-get/ ME Association position on graded exercise therapy (GET)]<ref name="MEA2007">{{Cite web|url=https://meassociation.org.uk/2008/05/mea-position-on-graded-exercise-therapy-get/|title=ME Association position on graded exercise therapy (GET)|last=The ME Association|first=|authorlink=ME Association|date=2008-05-11|website=ME Association|language=en-GB|archive-url=|archive-date=|access-date=2020-09-19}}</ref> - [[ME Association]]
*2008, [https://meassociation.org.uk/2008/05/mea-position-on-graded-exercise-therapy-get/ ME Association position on graded exercise therapy (GET)]<ref name="MEA2007">{{Cite web | url=https://meassociation.org.uk/2008/05/mea-position-on-graded-exercise-therapy-get/ | title = ME Association position on graded exercise therapy (GET) | last = The ME Association | first = | authorlink = ME Association | date = 2008-05-11 | website = ME Association|language=en-GB|archive-url=|archive-date=|access-date=2020-09-19}}</ref> - [[ME Association]]
*2010, At the [[Invest in ME International ME Conference]] Doctor [[Paul Cheney]] said "The whole idea that you can take a disease like this and exercise your way to health is foolishness. It is insane".<ref>{{Cite news|url=https://paradigmchange.me/me/exercise-quotes/|title=Quotes About Exercise Intolerance from M.E. Experts|work=Myalgic Encephalomyelitis|access-date=2018-10-13|language=en-US}}</ref>
*2010, At the [[Invest in ME International ME Conference]] Doctor [[Paul Cheney]] said "The whole idea that you can take a disease like this and exercise your way to health is foolishness. It is insane".<ref>{{Cite news | url=https://paradigmchange.me/me/exercise-quotes/ | title = Quotes About Exercise Intolerance from M.E. Experts|work=Myalgic Encephalomyelitis|access-date=2018-10-13|language=en-US}}</ref>
*2011, [http://iacfsme.org/PDFS/Reporting-of-Harms-Associated-with-GET-and-CBT-in.aspx Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome]<ref name=":2">{{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|author-link=Tom Kindlon|date=|website=IACFSME|archive-url=|archive-date=|access-date=}}</ref>
*2011, [http://iacfsme.org/PDFS/Reporting-of-Harms-Associated-with-GET-and-CBT-in.aspx Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome]<ref name=":2">{{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>
*2011, Health-related quality of life in patients with chronic fatigue syndrome: group [[Cognitive behavioral therapy|cognitive behavioural therapy]] and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up<ref>{{Cite journal|last=Núñez|first=Montserrat|author-link=Montserrat Núñez|last2=Fernández-Solà|first2=Joaquim|author-link2=|last3=Nuñez|first3=Esther|author-link3=|last4=Fernández-Huerta|first4=José-Manuel|author-link4=|last5=Godás-Sieso|first5=Teresa|author-link5=|last6=Gomez-Gil|first6=Esther|author-link6=|date=Mar 2011|title=Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up|url=http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.467.4965&rep=rep1&type=pdf|journal=Clinical Rheumatology|volume=30|issue=3|pages=381–389|doi=10.1007/s10067-010-1677-y|issn=1434-9949|pmid=21234629|quote=|via=}}</ref> [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.467.4965&rep=rep1&type=pdf (Full Text)]
*2011, Health-related quality of life in patients with chronic fatigue syndrome: group [[Cognitive behavioral therapy|cognitive behavioural therapy]] and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up<ref>{{Cite journal | last = Núñez | first = Montserrat | authorlink = Montserrat Núñez | last2 = Fernández-Solà | first2 = Joaquim | authorlink2 = | last3 = Nuñez | first3 = Esther | authorlink3 = | last4 = Fernández-Huerta | first4 = José-Manuel | authorlink4 = | last5 = Godás-Sieso | first5 = Teresa | authorlink5 = | last6 = Gomez-Gil | first6 = Esther | authorlink6 = | date = Mar 2011 | title = Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up | url =http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.467.4965&rep=rep1&type=pdf|journal=Clinical Rheumatology|volume=30|issue=3 | pages = 381–389|doi=10.1007/s10067-010-1677-y|issn=1434-9949|pmid=21234629|quote=|via=}}</ref> [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.467.4965&rep=rep1&type=pdf (Full Text)]
*2015, [http://www.meassociation.org.uk/wp-content/uploads/2015-ME-Association-Illness-Management-Report-No-decisions-about-me-without-me-30.05.15.pdf ME/CFS Illness Management Survey Results “No decisions about me without me”]<ref name=":3">{{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|archive-url=|archive-date=|access-date=}}</ref>
*2015, [http://www.meassociation.org.uk/wp-content/uploads/2015-ME-Association-Illness-Management-Report-No-decisions-about-me-without-me-30.05.15.pdf ME/CFS Illness Management Survey Results “No decisions about me without me”]<ref name=":3">{{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|archive-url=|archive-date=|access-date=}}</ref>
*2016, Do graded activity therapies cause harm in chronic fatigue syndrome?<ref>{{Cite journal|last=Kindlon|first=Tom|date=2017-03-20|title=Do graded activity therapies cause harm in chronic fatigue syndrome?|url=http://journals.sagepub.com/doi/full/10.1177/1359105317697323|journal=Journal of Health Psychology|language=en|volume=22|issue=9|pages=1146–1154|doi=10.1177/1359105317697323|issn=1359-1053|quote=|author-link=Tom Kindlon|via=}}</ref> [https://journals.sagepub.com/doi/full/10.1177/1359105317697323 (Full Text)] - Tom Kindlon
*2016, Do graded activity therapies cause harm in chronic fatigue syndrome?<ref>{{Cite journal | last = Kindlon | first = Tom | date = 2017-03-20 | title = Do graded activity therapies cause harm in chronic fatigue syndrome?| url = http://journals.sagepub.com/doi/full/10.1177/1359105317697323|journal=Journal of Health Psychology|language=en|volume=22|issue=9 | pages = 1146–1154|doi=10.1177/1359105317697323|issn=1359-1053|quote= | author-link = Tom Kindlon|via=}}</ref> [https://journals.sagepub.com/doi/full/10.1177/1359105317697323 (Full Text)] - Tom Kindlon
*2016, 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<ref name=":4">{{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> [http://www.tandfonline.com/doi/full/10.1080/21641846.2017.1259724 (Full Text)]
*2016, 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<ref name=":4">{{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> [http://www.tandfonline.com/doi/full/10.1080/21641846.2017.1259724 (Full Text)]
*2016, [https://undark.org/article/chronic-fatigue-graded-exercise-pace/ Worse Than the Disease: A popular therapy for chronic fatigue syndrome made many patients worse. Adding insult to injury, research supporting it is now unraveling.]<ref name=":6">{{Cite news|url=https://undark.org/article/chronic-fatigue-graded-exercise-pace/|title=For Chronic Fatigue Syndrome Sufferers, a Dubious Treatment Unravels|last=Tuller|first=David|date=2016-10-27|work=Undark|access-date=2018-11-27|archive-url=|archive-date=|language=en-US|author-link=David Tuller}}</ref>  
*2016, [https://undark.org/article/chronic-fatigue-graded-exercise-pace/ Worse Than the Disease: A popular therapy for chronic fatigue syndrome made many patients worse. Adding insult to injury, research supporting it is now unraveling.]<ref name=":6">{{Cite news | url=https://undark.org/article/chronic-fatigue-graded-exercise-pace/ | title = For Chronic Fatigue Syndrome Sufferers, a Dubious Treatment Unravels | last = Tuller | first = David | date = 2016-10-27|work=Undark|access-date=2018-11-27|archive-url=|archive-date=|language=en-US | authorlink = David Tuller}}</ref>  
*2017, Bias, misleading information and lack of respect for alternative views have distorted perceptions of [[ME/CFS|myalgic encephalomyelitis/chronic fatigue syndrome]] and its treatment<ref>{{Cite journal|last1=Goudsmit|first1=Ellen M| authorlink1=Ellen Goudsmit|last2=Howes|first2=Sandra|authorlink2=Sandra Howes
*2017, Bias, misleading information and lack of respect for alternative views have distorted perceptions of [[ME/CFS|myalgic encephalomyelitis/chronic fatigue syndrome]] and its treatment<ref>{{Cite journal | last1 = Goudsmit | first1 = Ellen M | authorlink1=Ellen Goudsmit | last2 = Howes | first2 = Sandra | authorlink2 = Sandra Howes | title =Bias, misleading information and lack of respect for alternative views have distorted perceptions of myalgic encephalomyelitis/chronic fatigue syndrome and its treatment|journal=J Health Psychol|volume=22|issue=9 | page = 1159-1167 | date = 2017|pmid=|doi=10.1177/1359105317707216}}</ref> [http://journals.sagepub.com/doi/full/10.1177/1359105317707216 (Full Text)]
|title=Bias, misleading information and lack of respect for alternative views have distorted perceptions of myalgic encephalomyelitis/chronic fatigue syndrome and its treatment|journal=J Health Psychol|volume=22|issue=9|page=1159-1167| date=2017|pmid=|doi=10.1177/1359105317707216}}</ref> [http://journals.sagepub.com/doi/full/10.1177/1359105317707216 (Full Text)]
*2017, [https://www.nytimes.com/2017/03/18/opinion/sunday/getting-it-wrong-on-chronic-fatigue-syndrome.html Getting it wrong on chronic fatigue syndrome]<ref>{{Cite news | url=https://www.nytimes.com/2017/03/18/opinion/sunday/getting-it-wrong-on-chronic-fatigue-syndrome.html | title = Opinion {{!}} Getting It Wrong on Chronic Fatigue Syndrome | last = Rehmeyer | first = Julie | date = 2018-03-18|work=New York Times|access-date=2018-11-27|archive-url=|archive-date=| publisher = New York Times | last2 = Tuller | first2 = David|publication-date=Jul 2018|language=en | authorlink = Julie Rehmeyer | authorlink2 = David Tuller}}</ref>  
*2017, [https://www.nytimes.com/2017/03/18/opinion/sunday/getting-it-wrong-on-chronic-fatigue-syndrome.html Getting it wrong on chronic fatigue syndrome]<ref>{{Cite news|url=https://www.nytimes.com/2017/03/18/opinion/sunday/getting-it-wrong-on-chronic-fatigue-syndrome.html|title=Opinion {{!}} Getting It Wrong on Chronic Fatigue Syndrome|last=Rehmeyer|first=Julie|date=2018-03-18|work=New York Times|access-date=2018-11-27|archive-url=|archive-date=|publisher=New York Times|last2=Tuller|first2=David|publication-date=Jul 2018|language=en|author-link=Julie Rehmeyer|author-link2=David Tuller}}</ref>  
*2018, Rethinking the treatment of Chronic Fatigue Syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT<ref>{{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> [https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3 (Full Text)]  
*2018, Rethinking the treatment of Chronic Fatigue Syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT<ref>{{Cite journal|last=Wilshire|first=Carolyn E.|author-link=Carolyn Wilshire|last2=Kindlon|first2=Tom|author-link2=Tom Kindlon|last3=Courtney|first3=Robert|author-link3=Robert Courtney|last4=Matthees|first4=Alem|author-link4=Alem Matthees|last5=Tuller|first5=David|author-link5=David Tuller|last6=Geraghty|first6=Keith|author-link6=Keith Geraghty|last7=Levin|first7=Bruce|author-link7=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> [https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3 (Full Text)]  
*2018, Graded exercise therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective and unsafe. Re-analysis of a Cochrane review<ref name=":5">{{Cite journal | last = Vink | first = Mark | authorlink = Mark Vink | last2 = Vink-Niese | first2 = Alexandra | authorlink2 = Alexandra Vink-Niese | date = 2018-10-08 | title = Graded exercise therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective and unsafe. Re-analysis of a Cochrane review | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176540/|journal=Health Psychology Open|volume=5|issue=2 | pages = |doi=10.1177/2055102918805187|issn=2055-1029|pmc=|pmid=30305916|quote=|via=}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176540/ (Full Text)]
*2018, Graded exercise therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective and unsafe. Re-analysis of a Cochrane review<ref name=":5">{{Cite journal|last=Vink|first=Mark|author-link=Mark Vink|last2=Vink-Niese|first2=Alexandra|author-link2=Alexandra Vink-Niese||date=2018-10-08|title=Graded exercise therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective and unsafe. Re-analysis of a Cochrane review|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176540/|journal=Health Psychology Open|volume=5|issue=2|pages=|doi=10.1177/2055102918805187|issn=2055-1029|pmc=|pmid=30305916|quote=|via=}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176540/ (Full Text)]
*2018, [https://healthycontrolblog.wordpress.com/2018/11/29/my-complaint-to-the-cochrane-governing-board-about-the-cochrane-review-of-exercise-for-chronic-fatigue-syndrome/ My complaint to the Cochrane Governing Board about the Cochrane review of Exercise for chronic fatigue syndrome]<ref>{{Cite news | url=https://healthycontrolblog.wordpress.com/2018/11/29/my-complaint-to-the-cochrane-governing-board-about-the-cochrane-review-of-exercise-for-chronic-fatigue-syndrome/ | title = My complaint to the Cochrane Governing Board about the Cochrane review of Exercise for chronic fatigue syndrome | last = Struthers | first = Caroline | date = 2018-11-29|work=Healthy Control|access-date=2018-11-29|archive-url=|archive-date=|language=en-US|quote= | author-link = Caroline Struthers}}</ref> - Caroline Struthers
*2018, [https://healthycontrolblog.wordpress.com/2018/11/29/my-complaint-to-the-cochrane-governing-board-about-the-cochrane-review-of-exercise-for-chronic-fatigue-syndrome/ My complaint to the Cochrane Governing Board about the Cochrane review of Exercise for chronic fatigue syndrome]<ref>{{Cite news|url=https://healthycontrolblog.wordpress.com/2018/11/29/my-complaint-to-the-cochrane-governing-board-about-the-cochrane-review-of-exercise-for-chronic-fatigue-syndrome/|title=My complaint to the Cochrane Governing Board about the Cochrane review of Exercise for chronic fatigue syndrome|last=Struthers|first=Caroline|date=2018-11-29|work=Healthy Control|access-date=2018-11-29|archive-url=|archive-date=|language=en-US|quote=|author-link=Caroline Struthers}}</ref> - Caroline Struthers
*2019, [https://www.meassociation.org.uk/2019/04/forward-me-and-oxford-brookes-university-announce-results-of-patient-survey-on-cbt-and-get-in-me-cfs-03-april-2019/ Forward-ME and Oxford Brookes University announce the results of patient survey on CBT and GET in ME/CFS]<ref name="OxBrookesMEA">{{Cite web | url=https://www.meassociation.org.uk/2019/04/forward-me-and-oxford-brookes-university-announce-results-of-patient-survey-on-cbt-and-get-in-me-cfs-03-april-2019 | date = 2019-04-03 | title = Forward-ME and Oxford Brookes University announce the results of patient survey on CBT and GET in ME/CFS|website=ME Association | last = Forward-ME | authorlink = Forward-ME | last2 = Oxford Brookes University|access-date= | first = | first2 = | authorlink2 = |archive-url=|archive-date=}}</ref>- Survey commissioned by NICE to help inform the review of the UK's ME/CFS treatment guidelines
*2019, [https://www.meassociation.org.uk/2019/04/forward-me-and-oxford-brookes-university-announce-results-of-patient-survey-on-cbt-and-get-in-me-cfs-03-april-2019/ Forward-ME and Oxford Brookes University announce the results of patient survey on CBT and GET in ME/CFS]<ref name="OxBrookesMEA">{{Cite web|url=https://www.meassociation.org.uk/2019/04/forward-me-and-oxford-brookes-university-announce-results-of-patient-survey-on-cbt-and-get-in-me-cfs-03-april-2019|date=2019-04-03|title=Forward-ME and Oxford Brookes University announce the results of patient survey on CBT and GET in ME/CFS|website=ME Association|last=Forward-ME|author-link=Forward-ME|last2=Oxford Brookes University|access-date=|first=|first2=|authorlink2=|archive-url=|archive-date=}}</ref>- Survey commissioned by NICE to help inform the review of the UK's ME/CFS treatment guidelines
::Survey results showed the effects of GET were:
::Survey results showed the effects of GET were:
::*Physical health deteriorated in 67% of ME/CFS patients as a result of GET
::*Physical health deteriorated in 67% of ME/CFS patients as a result of GET
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::*Mental health deteriorated in 53% of ME/CFS patients as a result of GET
::*Mental health deteriorated in 53% of ME/CFS patients as a result of GET
::*Mental health improved in 13% of ME/CFS patients as a result of GET
::*Mental health improved in 13% of ME/CFS patients as a result of GET
*2020, [https://meassociation.org.uk/wp-content/uploads/ForwardME-Letter-re-Covid-19-Management-and-Exercise-Caution-27.08.20.pdf Letter re Covid-19 Management and Exercise Caution]<ref name="GETcovidForwardME">{{Cite web|url=https://meassociation.org.uk/wp-content/uploads/ForwardME-Letter-re-Covid-19-Management-and-Exercise-Caution-27.08.20.pdf|date=2020-08-27|last=Forward-ME|author-link=Forward-ME|title =Letter re Covid-19 Management and Exercise Caution}}</ref> - [[Forward-ME]]
*2020, [https://meassociation.org.uk/wp-content/uploads/ForwardME-Letter-re-Covid-19-Management-and-Exercise-Caution-27.08.20.pdf Letter re Covid-19 Management and Exercise Caution]<ref name="GETcovidForwardME">{{Cite web | url=https://meassociation.org.uk/wp-content/uploads/ForwardME-Letter-re-Covid-19-Management-and-Exercise-Caution-27.08.20.pdf | date = 2020-08-27 | last = Forward-ME | authorlink = Forward-ME| title = Letter re Covid-19 Management and Exercise Caution}}</ref> - [[Forward-ME]]


==CDC withdrawal of GET treatment ==
==CDC withdrawal of GET treatment ==
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A number of different patients and patient charities have created <nowiki>#stopGET</nowiki> petitions to campaign for an end to graded exercise therapy treatment in [[ME/CFS]]:
A number of different patients and patient charities have created <nowiki>#stopGET</nowiki> petitions to campaign for an end to graded exercise therapy treatment in [[ME/CFS]]:
* Stop GET trials - MEAction<ref>{{Cite news|url=https://my.meaction.net/petitions/stop-graded-exercise-therapy-trials-for-me-cfs|title=STOP GRADED EXERCISE THERAPY TRIALS FOR ME/CFS|work=#MEAction|access-date=2018-10-20|language=en}}</ref>
* Stop GET trials - MEAction<ref>{{Cite news | url=https://my.meaction.net/petitions/stop-graded-exercise-therapy-trials-for-me-cfs | title = STOP GRADED EXERCISE THERAPY TRIALS FOR ME/CFS|work=#MEAction|access-date=2018-10-20|language=en}}</ref>
* Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW. - [[Robin Brown|Dr. Hng's]] [[United Kingdom|UK]] petition to stop GET and CBT
* Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW. - [[Robin Brown|Dr. Hng's]] [[United Kingdom|UK]] petition to stop GET and CBT
* The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision - a petition the ME Association delivered to Andrew Dillon at NICE  
* The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision - a petition the ME Association delivered to Andrew Dillon at NICE  
* Suspend all trials of graded exercise therapy in children and adults with ME/CFS - [[UK]] parliament petition (archived)<ref>{{Cite news|url=https://petition.parliament.uk/petitions/166601|title=Archived Petition: Suspend all trials of graded exercise therapy in children and adults with ME/CFS|work=Petitions - UK Government and Parliament|access-date=2018-10-20|language=en-GB}}</ref>
* Suspend all trials of graded exercise therapy in children and adults with ME/CFS - [[UK]] parliament petition (archived)<ref>{{Cite news | url=https://petition.parliament.uk/petitions/166601 | title = Archived Petition: Suspend all trials of graded exercise therapy in children and adults with ME/CFS|work=Petitions - UK Government and Parliament|access-date=2018-10-20|language=en-GB}}</ref>


== GET after COVID-19 ==
== GET after COVID-19 ==
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==Notable studies==
==Notable studies==
*2004, Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability <ref>{{Cite journal|last=Nijs|first=Jo|author-link=Jo Nijs|last2=Vanherberghen|first2=Katrien|author-link2=Katrien Vanherberghen|last3=Duquet|first3=William|author-link3=William Duquet|last4=De Meirleir|first4=Kenny|author-link4=Kenny De Meirleir|date=2004-08-01|title=Chronic Fatigue Syndrome: Lack of Association Between Pain-Related Fear of Movement and Exercise Capacity and Disability|url=https://doi.org/10.1093/ptj/84.8.696|journal=Physical Therapy|language=en|volume=84|issue=8|pages=|doi=10.1093/ptj/84.8.696|issn=1538-6724|quote=These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with CFS who are experiencing widespread muscle or joint pain.|via=}}</ref> [https://academic.oup.com/ptj/article/84/8/696/2857531 (Full Text)]
*2004, Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability <ref>{{Cite journal | last = Nijs | first = Jo | author-link =Jo Nijs | last2 = Vanherberghen | first2 = Katrien | authorlink2 = Katrien Vanherberghen | last3 = Duquet | first3 = William | authorlink3 = William Duquet | last4 = De Meirleir | first4 = Kenny | authorlink4 = Kenny De Meirleir | date = 2004-08-01 | title = Chronic Fatigue Syndrome: Lack of Association Between Pain-Related Fear of Movement and Exercise Capacity and Disability| url = https://doi.org/10.1093/ptj/84.8.696|journal=Physical Therapy|language=en|volume=84|issue=8 | pages = |doi=10.1093/ptj/84.8.696|issn=1538-6724|quote=These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with CFS who are experiencing widespread muscle or joint pain.|via=}}</ref> [https://academic.oup.com/ptj/article/84/8/696/2857531 (Full Text)]
*2009, A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS<ref name=":0">{{Cite journal|last=Twisk|first=Frank N. M.|last2=Maes|first2=Michael|date=2009|title=A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS|url=https://www.ncbi.nlm.nih.gov/m/pubmed/19855350/|journal=Neuro Endocrinology Letters|volume=30|issue=3|pages=284–299|issn=0172-780X|pmid=19855350}}</ref> [https://www.ncbi.nlm.nih.gov/m/pubmed/19855350/ (Abstract)]
*2009, A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS<ref name=":0">{{Cite journal | last = Twisk | first = Frank N.M. | last2 = Maes | first2 = Michael | date = 2009 | title = A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS| url = https://www.ncbi.nlm.nih.gov/m/pubmed/19855350/|journal=Neuro Endocrinology Letters|volume=30|issue=3 | pages = 284–299|issn=0172-780X|pmid=19855350}}</ref> [https://www.ncbi.nlm.nih.gov/m/pubmed/19855350/ (Abstract)]
*2016, Exercise therapy for chronic fatigue syndrome<ref name=":1">{{Cite journal|last=Larun|first=Lillebeth|last2=Brurberg|first2=Kjetil G.|last3=Odgaard‐Jensen|first3=Jan|last4=Price|first4=Jonathan R.|date=2016|title=Exercise therapy for chronic fatigue syndrome|url=https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003200.pub5/abstract|journal=Cochrane Database of Systematic Reviews|language=en|issue=6|doi=10.1002/14651858.CD003200.pub5|issn=1465-1858}}</ref> [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003200.pub5/abstract (Full Text)]
*2016, Exercise therapy for chronic fatigue syndrome<ref name=":1">{{Cite journal | last = Larun | first = Lillebeth | last2 = Brurberg | first2 = Kjetil G. | last3 = Odgaard‐Jensen | first3 = Jan | last4 = Price | first4 = Jonathan R. | date = 2016 | title=Exercise therapy for chronic fatigue syndrome| url = https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003200.pub5/abstract|journal=Cochrane Database of Systematic Reviews|language=en|issue=6|doi=10.1002/14651858.CD003200.pub5|issn=1465-1858}}</ref> [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003200.pub5/abstract (Full Text)]
*2016, Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions.<ref>{{Cite journal|last=Cvejic|first=Erin|last2=Lloyd|first2=Andrew R.|last3=Vollmer-Conna|first3=Uté|date=2016|title=Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions|url=https://www.ncbi.nlm.nih.gov/pubmed/26995250|journal=Comprehensive Psychiatry|volume=66|pages=166–175|doi=10.1016/j.comppsych.2016.02.002|issn=1532-8384|pmid=26995250|via=}}</ref> [[pubmed:26995250|(Abstract)]]
*2016, Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions.<ref>{{Cite journal | last = Cvejic | first = Erin | last2 = Lloyd | first2 = Andrew R. | last3 = Vollmer-Conna | first3 = Uté | date = 2016 | title=Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions| url = https://www.ncbi.nlm.nih.gov/pubmed/26995250|journal=Comprehensive Psychiatry|volume=66 | pages = 166–175|doi=10.1016/j.comppsych.2016.02.002|issn=1532-8384|pmid=26995250|via=}}</ref> [[pubmed:26995250|(Abstract)]]
*2017, PACE investigators' response is misleading regarding patient survey results<ref>{{Cite journal|last=Kirke|first=Karen D|author-link=|date=2017-05-11|title=PACE investigators’ response is misleading regarding patient survey results|url=https://doi.org/10.1177/1359105317703787|journal=Journal of Health Psychology|language=en|volume=22|issue=9|pages=1168–1176|doi=10.1177/1359105317703787|issn=1359-1053|quote=|via=}}</ref> [https://doi.org/10.1177%2F1359105317703787 (Full Text)]
*2017, PACE investigators' response is misleading regarding patient survey results<ref>{{Cite journal | last = Kirke | first = Karen D | authorlink = | date = 2017-05-11 | title = PACE investigators’ response is misleading regarding patient survey results| url = https://doi.org/10.1177/1359105317703787|journal=Journal of Health Psychology|language=en|volume=22|issue=9 | pages = 1168–1176|doi=10.1177/1359105317703787|issn=1359-1053|quote=|via=}}</ref> [https://doi.org/10.1177%2F1359105317703787 (Full Text)]
*2018, Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT <ref>{{Cite journal|last=Wilshire|first=Carolyn E.|author-link=Carolyn Wilshire|last2=Kindlon|first2=Tom|author-link2=Tom Kindlon|last3=Courtney|first3=Robert|author-link3=Robert Courtney|last4=Matthees|first4=Alem|author-link4=Alem Matthees|last5=Tuller|first5=David|author-link5=David Tuller|last6=Geraghty|first6=Keith|author-link6=Keith Geraghty|last7=Levin|first7=Bruce|author-link7=|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|quote=|via=}}</ref> [https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3 (Full Text)]
*2018, Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT <ref>{{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 = | 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|quote=|via=}}</ref> [https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3 (Full Text)]


* 2019, 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<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> [https://www.meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Final-Consolidated-Report-03.04.19.pdf (Full text)]
* 2019, 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<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> [https://www.meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Final-Consolidated-Report-03.04.19.pdf (Full text)]


==Learn more==
==Learn more==

Latest revision as of 17:05, April 2, 2023

Increasingvalueschart-gradedexercise.png

Graded exercise therapy (GET) is a form of physical therapy for the treatment of chronic fatigue syndrome (CFS) where physical activity is gradually increased over time, regardless of how the patient is feeling and ignoring any increased symptoms or new symptoms. GET was offered as a primary treatment for ME/CFS to UK patients by the National Health Service (NHS), as specified in the NICE guidelines from 2007-2021, but the GET recommendation was removed by the 2021 NICE guidelines update because of high rates of harm.[1] The use of Graded Exercise Therapy as a treatment is based on the disputed deconditioning hypothesis, and the highly controversial biopsychosocial model (BPS) of ME/CFS.[2]

Alternative names used for graded exercise therapy include Graded Activity Management (GAM), and Graded Activity Therapy (GAT).[3][4][5]

Graded Activity Therapy is defined in several different ways:

Evidence[edit | edit source]

Patient reports of harm[edit | edit source]

Clinical trials have resulted in mixed results.[2][8][9] Surveys of patients conducted by patient charities have universally found Graded Exercise Therapy to be harmful, although a minority of patients found it helped them or simply ineffective.[10][11] A number of severely ill patients have reported that starting Graded Exercise Therapy with moderate symptoms cause a severe escalation of symptoms, leaving them permanently worse. Two highly influential peer-reviewed articles often used to support the use of Graded Exercise Therapy, the Cochrane review and the PACE trial, have had widescale calls for retraction based on criticism of the scientific method and standards used.[9]

Robin Brown, a British doctor with ME/CFS has created petition that many thousands have signed calling for GET and related CBT to be removed from the UK treatment guidelines immediately.[12]

Physical fitness unchanged[edit | edit source]

A number of studies by proponents of GET have found that it did not improve fitness, when self-rated perception of fatigue did improve after GET, no improvements in exercise capacity were statistically significant.[2][13][14] The controversial PACE trial's 6 minute walk test results showed those successfully completing GET were unable to walk as far as older patients awaiting a lung transplant or those with heart failure; data that was omitted from the original trial report.[14]

Patient analysis of PACE results[edit | edit source]

Graham McPhee and others created videos investigating the PACE trial data in relation to GET.[15][16] Several re-analyses of the PACE trial results have been published since the detailed PACE trial data was released into the public domain.[14]

Fear of exercise[edit | edit source]

The PACE trial investigators have stated that they believe a significant maintaining factor in the persistence of ME/CFS is fear of exercise.[17] This claim has been criticized as unsupported by trial results.[18] A study by Nijs et al. in 2004 concluded:

Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability

These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with CFS who are experiencing widespread muscle or joint pain.

Jo Nij, Katrien Vanherberghen, William Duquet & Kenny De Meirleir (2004)


Doctors who are patients with ME/CFS[edit | edit source]

Graded exercise therapy and CBT. "As a physician bedridden with myalgic encephalomyelitis (ME) for more than a decade who is totally dependent on others, all thanks to a major relapse caused by GET, I am in a unique position to answer how harmful GET and cognitive behavioral therapy (CBT) really are. The basis of these therapies is false illness beliefs, meaning that it is all in the mind. These beliefs ignore all of the evidence that ME is a physical disease, such as intracellular immune dysfunctions, which not only restrict exercise capacity but also worsen with exercise (2)." - Maik Speedy (2015). Annals of Internal Medicine.
Graded exercise therapy caused a permanent relapse that left Dr Maik Speedy bedridden.


A number of doctors diagnosed with ME/CFS have shared their personal experiences of graded exercise therapy or have spoken out against GET to both other doctors and patients. These include:

NICE's 2019 patient survey[edit | edit source]

An independent patient survey of UK patients was comissioned by NICE in 2019, as part of the NHS guideline review process.[19]

Effects of GET on ME/CFS
improved no change worsened
physical health 13% 12% 67%
mental health 13% 26% 53%
ME/CFS symptoms after GET
yes no
one of more symptoms worsened because of GET 81% 13%
new symptom(s) developed because of GET 37%
Patient had severe ME/CFS
before treatment 13%
after treatment 35%

Articles explaining GET not appropriate for ME/CFS[edit | edit source]

Describing graded exercise in comparison with symptom-contingent graded exercise therapy or pacing

Criticism[edit | edit source]

Survey results showed the effects of GET were:
  • Physical health deteriorated in 67% of ME/CFS patients as a result of GET
  • Physical health improved in 13% of ME/CFS patients as a result of GET
  • One or more symptoms worsened in 81% because of GET, particularly pain and fatigue
  • One or more new symptoms developed in 37% because of GET
  • No symptoms worsened for 13% because of GET
  • Mental health deteriorated in 53% of ME/CFS patients as a result of GET
  • Mental health improved in 13% of ME/CFS patients as a result of GET

CDC withdrawal of GET treatment[edit | edit source]

July 3, 2017, The Centers for Disease Control and Prevention's (CDC) website Chronic Fatigue Syndrome page has been changed to "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)" and GET and CBT recommendations have been removed.[36][37]

StopGET petitions[edit | edit source]

A number of different patients and patient charities have created #stopGET petitions to campaign for an end to graded exercise therapy treatment in ME/CFS:

  • Stop GET trials - MEAction[38]
  • Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW. - Dr. Hng's UK petition to stop GET and CBT
  • The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision - a petition the ME Association delivered to Andrew Dillon at NICE
  • Suspend all trials of graded exercise therapy in children and adults with ME/CFS - UK parliament petition (archived)[39]

GET after COVID-19[edit | edit source]

Concerns have been raised about the potential harms of graded exercise therapy to patients who have developed fatigue or other symptoms after COVID-19, patients needing rehabilitation after COVID-19, and patients who may develop postviral ME/CFS after COVID-19.[35]

Notable studies[edit | edit source]

  • 2004, Chronic Fatigue Syndrome: Lack of Association between Pain-Related Fear of Movement and Exercise Capacity and Disability [40] (Full Text)
  • 2009, A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS[2] (Abstract)
  • 2016, Exercise therapy for chronic fatigue syndrome[8] (Full Text)
  • 2016, Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions.[41] (Abstract)
  • 2017, PACE investigators' response is misleading regarding patient survey results[42] (Full Text)
  • 2018, Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT [43] (Full Text)
  • 2019, 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[44] (Full text)

Learn more[edit | edit source]

See also[edit | edit source]

References[edit | edit source]

  1. NICE Guideline Development Group (October 29, 2021). "Myalgic Encephalomyelitis (or Encephalopathy)/Chronic Fatigue Syndrome:diagnosis and management. NICE guideline". National Institute for Health and Care Excellence.
  2. 2.0 2.1 2.2 2.3 Twisk, Frank N.M.; Maes, Michael (2009). "A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS". Neuro Endocrinology Letters. 30 (3): 284–299. ISSN 0172-780X. PMID 19855350.
  3. 3.0 3.1 Campling, Frankie; Sharpe, Michael (July 2, 2008). Chronic Fatigue Syndrome. OUP Oxford. p. 157. ISBN 978-0-19-157971-4. 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.
  4. 4.0 4.1 South Tees Specialist CFS/ME Service (2018). "Group Rehabilitation Programme for people with CFS / ME. SESSION 1" (PDF). South Tees Hospitals NHS Foundation. Slide 17. Retrieved November 3, 2021. GRADED EXERCISE THERAPY = GRADED ACTIVITY THERAPY
  5. "ELFT - Services - Bedfordshire Chronic Fatigue Service". East London NHS. October 30, 2021. Retrieved November 3, 2021. NICE recommended Cognitive Behaviour Therapy (CBT) and Graded Activity Management (GAM)
  6. Cheshire, Anna; Ridge, Damien; Clark, Lucy; White, Peter (January 30, 2020). "Guided graded Exercise Self-help for chronic fatigue syndrome: patient experiences and perceptions". Disability and Rehabilitation. 42 (3): 368–377. doi:10.1080/09638288.2018.1499822. ISSN 0963-8288. PMID 30325677.
  7. "Chronic Fatigue Syndrome (CFS)/ Myalgic Encephalopathy (ME) Management Programme". Salford Royal NHS Foundation Trust. 2018. Retrieved November 3, 2021. Scheduling Rest and Activity
    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.
  8. 8.0 8.1 Larun, Lillebeth; Brurberg, Kjetil G.; Odgaard‐Jensen, Jan; Price, Jonathan R. (2016). "Exercise therapy for chronic fatigue syndrome". Cochrane Database of Systematic Reviews (6). doi:10.1002/14651858.CD003200.pub5. ISSN 1465-1858.
  9. 9.0 9.1 9.2 Vink, Mark; Vink-Niese, Alexandra (October 8, 2018). "Graded exercise therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective and unsafe. Re-analysis of a Cochrane review". Health Psychology Open. 5 (2). doi:10.1177/2055102918805187. ISSN 2055-1029. PMID 30305916.
  10. 10.0 10.1 Kindlon, Tom. "Bulletin of the IACFS/ME 59 Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". IACFSME.
  11. 11.0 11.1 "ME/CFS Illness Management Survey Results - "No decisions about me without me" Part 1" (PDF). meassociation.org. May 2015.
  12. Brown, Robin. "NICE stop harming ME/CFS patients - Take CBT and GET out of the CFS guidelines NOW! | Sign the Petition". Change.org. Retrieved November 13, 2018.
  13. Moss-Morris, Rona; Sharon, Cynthia; Tobin, Roseanne; Baldi, James C. (March 2005). "A Randomized Controlled Graded Exercise Trial for Chronic Fatigue Syndrome: Outcomes and Mechanisms of Change". Journal of Health Psychology. 10 (2): 245–259. doi:10.1177/1359105305049774. ISSN 1359-1053.
  14. 14.0 14.1 14.2 14.3 Wilshire, Carolyn; Kindlon, Tom; Matthees, Alem; McGrath, Simon (December 14, 2016). "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". Fatigue: Biomedicine, Health & Behavior. 5 (1): 43–56. doi:10.1080/21641846.2017.1259724. ISSN 2164-1846.
  15. "PACEindividuals". Vimeo. Retrieved October 13, 2018.
  16. "PACEgraph". Vimeo. Retrieved October 13, 2018.
  17. Torjesen, Ingrid (October 28, 2015). "Tackling fear about exercise produces long term benefit in chronic fatigue syndrome". BMJ. 351: h5771. doi:10.1136/bmj.h5771. ISSN 1756-1833. PMID 26511755.
  18. "Objective measures found a lack of improvement for CBT & GET in the PACE Trial: subjective improvements may simply represent response biases or placebo effects in this non-blinded trial". The BMJ. October 13, 2018.
  19. Forward-ME (April 3, 2019). "Forward-ME Executive Summary" (PDF). ME Association (pdf).
  20. Crowhurst, Greg (September 3, 2005). "Issues relating to Severe ME And Graded Exercise" (PDF). Stonebird.
  21. 21.0 21.1 Tuller, David (October 27, 2016). "For Chronic Fatigue Syndrome Sufferers, a Dubious Treatment Unravels". Undark. Retrieved November 27, 2018.
  22. Maxted, Camilla (August 6, 2017). "This Is Why I Quit Exercise Therapy". BuzzFeed. Retrieved November 29, 2018.
  23. Kindlon, Tom (March 20, 2017). "Do graded activity therapies cause harm in chronic fatigue syndrome?". Journal of Health Psychology. 22 (9): 1146–1154. doi:10.1177/1359105317697323. ISSN 1359-1053.
  24. Goudsmit, Ellen M.; Nijs, Jo; Jason, Leonard A.; Wallman, Karen E. (December 19, 2011). "Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document". Disability and Rehabilitation. 34 (13): 1140–1147. doi:10.3109/09638288.2011.635746. ISSN 0963-8288.
  25. Michiel, Tack (July 4, 2019). "Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome". BMJ Medical Humanities Blog. Retrieved July 9, 2019.
  26. The ME Association (May 11, 2008). "ME Association position on graded exercise therapy (GET)". ME Association. Retrieved September 19, 2020.
  27. "Quotes About Exercise Intolerance from M.E. Experts". Myalgic Encephalomyelitis. Retrieved October 13, 2018.
  28. Núñez, Montserrat; Fernández-Solà, Joaquim; Nuñez, Esther; Fernández-Huerta, José-Manuel; Godás-Sieso, Teresa; Gomez-Gil, Esther (March 2011). "Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up". Clinical Rheumatology. 30 (3): 381–389. doi:10.1007/s10067-010-1677-y. ISSN 1434-9949. PMID 21234629.
  29. Kindlon, Tom (March 20, 2017). "Do graded activity therapies cause harm in chronic fatigue syndrome?". Journal of Health Psychology. 22 (9): 1146–1154. doi:10.1177/1359105317697323. ISSN 1359-1053.
  30. Goudsmit, Ellen M; Howes, Sandra (2017). "Bias, misleading information and lack of respect for alternative views have distorted perceptions of myalgic encephalomyelitis/chronic fatigue syndrome and its treatment". J Health Psychol. 22 (9): 1159-1167. doi:10.1177/1359105317707216.
  31. Rehmeyer, Julie; Tuller, David (March 18, 2018). "Opinion | Getting It Wrong on Chronic Fatigue Syndrome". New York Times. New York Times (published July 2018). Retrieved November 27, 2018.
  32. Wilshire, Carolyn E.; Kindlon, Tom; Courtney, Robert; Matthees, Alem; Tuller, David; Geraghty, Keith; Levin, Bruce (March 22, 2018). "Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT". BMC Psychology. 6 (1). doi:10.1186/s40359-018-0218-3. ISSN 2050-7283. PMC 5863477. PMID 29562932.
  33. Struthers, Caroline (November 29, 2018). "My complaint to the Cochrane Governing Board about the Cochrane review of Exercise for chronic fatigue syndrome". Healthy Control. Retrieved November 29, 2018.
  34. Forward-ME; Oxford Brookes University (April 3, 2019). "Forward-ME and Oxford Brookes University announce the results of patient survey on CBT and GET in ME/CFS". ME Association.
  35. 35.0 35.1 Forward-ME (August 27, 2020). "Letter re Covid-19 Management and Exercise Caution" (PDF).
  36. Trial By Error: The CDC Drops CBT/GET - Virology Blog
  37. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome - CDC.gov
  38. "STOP GRADED EXERCISE THERAPY TRIALS FOR ME/CFS". #MEAction. Retrieved October 20, 2018.
  39. "Archived Petition: Suspend all trials of graded exercise therapy in children and adults with ME/CFS". Petitions - UK Government and Parliament. Retrieved October 20, 2018.
  40. Nijs, Jo; Vanherberghen, Katrien; Duquet, William; De Meirleir, Kenny (August 1, 2004). "Chronic Fatigue Syndrome: Lack of Association Between Pain-Related Fear of Movement and Exercise Capacity and Disability". Physical Therapy. 84 (8). doi:10.1093/ptj/84.8.696. ISSN 1538-6724. These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with CFS who are experiencing widespread muscle or joint pain.
  41. Cvejic, Erin; Lloyd, Andrew R.; Vollmer-Conna, Uté (2016). "Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions". Comprehensive Psychiatry. 66: 166–175. doi:10.1016/j.comppsych.2016.02.002. ISSN 1532-8384. PMID 26995250.
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