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===Adaptive pacing therapy (APT) === A modified form of pacing is called adapative pacing therapy (APT). This version was promoted by [[Action for ME]]<ref name=":12" /> and was used in the [[PACE trial]]<ref>Cox et al. (2004) [https://www.qmul.ac.uk/wolfson/media/wolfson/current-projects/2.apt-participant-manual.pdf Manual for participants Adaptive Pacing Therapy for CFS/ME.] </ref> as an alternative to [[cognitive behavioral therapy]], [[graded exercise therapy]] and specialist medical care. There are some major differences between APT and the original form of pacing advocated by Goudsmit. The former for example stresses splitting up activities, while this is not necessarily an advice used in the latter. APT seems more influenced by chronic pain literature as it gives more weight to planning and building up activities. A booklet on pacing, produced by Action for ME explains to patients: “you are likely to notice a temporary increase in stiffness or fatigue when increasing your activity levels. This is normal and your body will need a few days to adjust and adapt.”<ref name=":12" /> No such advice is given in the pacing, developed by Goudsmit or Jason as this may not be adequate in the treatment of patients with ME/CFS. One of the (anonymous) participants in the 2015 ME association survey, for example, complained that pacing put too much emphasis on increasing activity:<blockquote>"It taught me to listen to my body and not ignore symptoms and I gradually began to see the link between exercise/activity and delayed fatigue, which I hadn't done beforehand. That was crucial in slowing down my deterioration. But I wish someone had said 'if you are experiencing symptoms you should rest' – the message was, 'you can get worse briefly but symptoms should then go again'. I kept waiting for them to go and they never did. Then I had a massive relapse which I have not recovered from. Pacing is not very satisfactory – it is full of confusing contradictory messages […] I felt the emphasis was too heavily on increasing activity – I should have been told to rest.”<ref name=":7" /></blockquote>These criticisms seem to apply to APT, and not to pacing. Another major difference is that APT promotes the use of preemptive rest. In the [[PACE trial]] for example patients were advised to follow the 70%-rule, meaning they shouldn’t go beyond 70% of their perceived energy. This is also not an element in the writings of Goudsmit or Jason, where patients are advised to correctly balance perceived energy and energy expenditure. Telling ME/CFS patients to do even less than their perceived energy limit might have negative consequences, as was noticed by Leonard Jason: “By doing less than what patients have the energy to do, and the resulting preemptive rest, this intervention could even have the unwitting effects of increasing social isolation.”<ref name=":13">{{Cite journal | last= Jason | first = Leonard A| date = 2017-08-01| title = The PACE trial missteps on pacing and patient selection | url =https://doi.org/10.1177/1359105317695801|journal=Journal of Health Psychology|language=en|volume=22|issue=9|pages=1141–1145|doi=10.1177/1359105317695801|issn=1359-1053}}</ref> This was what Goudsmit found in the clinical trial where the protocol of Ho Yen was tested. The treatment arm also included preemptive rest and some patients said they felt isolated as a result of the prescribed reduction in activity.<ref name=":2" /> Finally, APT proposes pacing as a therapy, while Goudsmit has emphasized the opposite. She explicitly warned that: “both the rationale behind pacing and the findings from controlled trials do not support the promotion by some patient groups of pacing as a “therapy” for CFS. […] given the lack of evidence that this strategy can alleviate a range of symptoms and promote healing, descriptions of pacing as a form of therapy may be construed as misleading.”<ref name=":0" /> The findings of the PACE-trial, analyzed according to the original protocol, did not find a significant difference between APT, specialist medical care, graded exercise therapy or cognitive behavioral therapy. Jason remarked that the label APT, included much more than pacing: “It is important to note that APT (Cox et al., 2004) also included advice on stress management, sleep, and so on, and this makes it difficult to determine what was effective or ineffective if one cannot separate the effects […] the authors evaluated APT, not solely pacing.”<ref name=":13" /> According to Goudsmit and Howes, “the differences between APT and pacing almost certainly explain the discrepancy between the results relating to the former, and the research as well as positive experiences of pacing reported by patients in surveys conducted by support groups.”<ref>{{Cite journal | last = Goudsmit | first = Ellen | last2 = Howes | first2 = Sandra | date = 2017-08-01| title = Bias, misleading information and lack of respect for alternative views have distorted perceptions of myalgic encephalomyelitis/chronic fatigue syndrome and its treatment|url=https://doi.org/10.1177/1359105317707216|journal=Journal of Health Psychology|language=en|volume=22|issue=9|pages=1159–1167|doi=10.1177/1359105317707216|issn=1359-1053}}</ref>
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