Graded activity therapy

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Graded Activity Therapy or GAT is an alternative name for the controversial treatment Graded Exercise Therapy (GET).[1][2]Graded Activity Management (GAM) is another term used interchangeably with Graded Activity Therapy and Graded Exercise Therapy.[3]

Graded Activity Therapy is defined in several different ways:

Theory[edit | edit source]

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.[5] The aim it to continue increase until full health is achieved, with CFS/ME assumed to be "curable" medically unexplained symptoms despite the known 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.[6]

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 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 "perpetuate" the illness.[6][7][8][9][10][11]

PACE trial[edit | edit source]

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.[12][13] 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 CDC in the United States,[14][15] the Dutch Health Council in the Netherlands,[16] and by NICE and the NHS in England and Wales.[17]

NICE guidelines 2021[edit | edit source]

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.[17][18]

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.[3] 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.[5]

Criticisms[edit | edit source]

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.[19][20][21][18]

See also[edit | edit source]

References[edit | edit source]

  1. 1.01.1 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.
  2. 2.02.1 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
  3. 3.03.1 "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)
  4. 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.
  5. 5.05.15.2 "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.
  6. 6.06.1 Geraghty, Keith; Jason, Leonard; Sunnquist, Madison; Tuller, David; Blease, Charlotte; Adeniji, Charles (January 1, 2019). "The 'cognitive behavioural model' of chronic fatigue syndrome: Critique of a flawed model". Health Psychology Open. 6 (1): 2055102919838907. doi:10.1177/2055102919838907. ISSN 2055-1029.
  7. Geraghty, Keith J.; Blease, Charlotte (June 21, 2018). "Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter". Disability and Rehabilitation: 1–10. doi:10.1080/09638288.2018.1481149. ISSN 0963-8288.
  8. Geraghty, Keith J.; Esmail, Aneez (August 1, 2016). "Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm?". Br J Gen Pract. 66 (649): 437–438. doi:10.3399/bjgp16X686473. ISSN 0960-1643. PMID 27481982.
  9. "PACE Trial: People with ME - Hansard". hansard.parliament.uk (Volume 636 ed.). February 20, 2018. Retrieved October 29, 2018.
  10. Invest in ME Research. "Notes on the Ineffectiveness of the Biopsychosocial Model for Treating Myalgic Encephalomyelitis" (PDF). Retrieved October 30, 2018.
  11. 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.org.
  12. 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.
  13. 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.
  14. "IOM 2015 Diagnostic Criteria | Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Centers for Disease Control. January 27, 2021. Retrieved February 25, 2021.
  15. "Symptoms | Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Centers for Disease Control. January 27, 2021. Retrieved February 25, 2021.
  16. Twisk, Frank (2018). "Dutch Health Council advisory report on Myalgic Encephalomyelitis and Chronic Fatigue Syndrome: Taking the wrong turn". Diagnostics. 8 (2). doi:10.3390/diagnostics8020034.
  17. 17.017.1 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.
  18. 18.018.1 Oxford Clinical Allied Technology and Trials Services Unit (OxCATTS) (February 27, 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" (PDF). Oxford Brookes University.
  19. 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.org.
  20. https://www.tandfonline.com/doi/abs/10.3109/09638288.2013.797508
  21. "ME/CFS Illness Management Survey Results - "No decisions about me without me" Part 1" (PDF). meassociation.org. ME Association. May 2015.

graded exercise therapy (GET) - A gradual increase in exercise or activity, according to a pre-defined plan. Focuses on overcoming the patient's alleged unhelpful illness beliefs that exertion can exacerbate symptoms, rather than on reversing physical deconditioning. Considered controversial, and possibly harmful, in the treatment or management of ME. One of the treatment arms of the controversial PACE trial.

graded exercise therapy (GET) - A gradual increase in exercise or activity, according to a pre-defined plan. Focuses on overcoming the patient's alleged unhelpful illness beliefs that exertion can exacerbate symptoms, rather than on reversing physical deconditioning. Considered controversial, and possibly harmful, in the treatment or management of ME. One of the treatment arms of the controversial PACE trial.

cognitive behavioral therapy (CBT) - A type of psychotherapy geared toward modifying alleged unhealthy thinking, behaviors or illness beliefs. One of the treatment arms used in the controversial PACE trial.

myalgic encephalomyelitis (M.E.) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

NICE guidelines Clinical guidelines used in the UK.

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From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history.