NICE guidelines

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The NICE guidelines are the UK's National Health Service (NHS) diagnostic and treatment guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), but are written only for use in England and Wales. In 2018, NICE began appointing a committee of professionals and lay members to NICE guidelines review committee to rewrite the guidelines.[1] The new ME/CFS guidelines were published in October 2021, and include changes to the diagnostic criteria and recommended treatments.[2]

NICE, the National Institute for Health and Care Excellence, is a UK government body that approves and recommends treatments for use within the NHS with the mission to improve health and social care through evidence-based guidance.[3]

NICE Guidelines Review for CFS/ME (2017-2021)
[edit | edit source]

NICE initially announced that the 2007 guidelines would not be updated as a result of the 2017 review, but then changed this decision in September 20, 2017; the new ME/CFS guideline were due in April 2020 but were finally published in October 2021. The new guidelines refer to ME/CFS rather than CFS/ME.[4][5]

Reasons for the update[edit | edit source]

Authors[edit | edit source]

List of the NICE ME/CFS Guideline Development Group (GDG) review panel members:

Stakeholders[edit | edit source]

A large number of organizations registered as stakeholders, and stakeholder meetings began in 2018.[17]

NICE ME/CFS Diagnostic criteria (from Oct 2021)[edit | edit source]

[2]

Suspected ME/CFS[edit | edit source]

  • the person has had all of the persistent symptoms in the box below for a minimum of 6 weeks in adults (4 weeks in children and young people) and
  • the person's ability to engage in occupational, educational, social or personal activities is significantly reduced from pre‑illness levels and
  • symptoms are not explained by another condition.

All the following symptoms are required for suspected ME/CFS:

Definitions:

  • Activity

Any effort that uses energy, which includes cognitive, emotional and social activity as well as physical activity. Different activities combine and interact to cause a cumulative impact for the person.

  • Fatigue
    Fatigue in ME/CFS typically has the following components:
    • feeling flu-like, especially in the early days of the illness
    • restlessness or feeling 'wired but tired'
    • low energy or a lack of physical energy to start or finish activities of daily living and the sensation of being 'physically drained'
    • cognitive fatigue that worsens existing difficulties
    • rapid loss of muscle strength or stamina after starting an activity, causing for example, sudden weakness, clumsiness, lack of coordination, and being unable to repeat physical effort consistently.
  • Post-exertional malaise

The worsening of symptoms that can follow minimal cognitive, physical, emotional or social activity, or activity that could previously be tolerated. Symptoms can typically worsen 12 to 48 hours after activity and last for days or even weeks, sometimes leading to a relapse. Post-exertional malaise may also be referred to as post-exertional symptom exacerbation.

  • Unrefreshing sleep

Unrefreshing sleep means sleep that is non-restorative. Even after a full night's sleep, people do not feel refreshed. People with ME/CFS often report waking up exhausted and feeling as if they have not slept at all, no matter how long they were asleep.[2]

Treatments[edit | edit source]

Neurological disease[edit | edit source]

The revised ME/CFS guideline clearly states that ME/CFS is a physical illness:

Be aware that ME/CFS... is a complex, chronic medical condition affecting multiple body systems and its pathophysiology is still being investigated

NICE guideline for ME/CFS 2021 [NG206] p.9


Near the end in the guideline, the Context section also states it is classified as a Disease of the Nervous System using ICD-10 code G93.3 by the World Health Organization, and by SNOWMED, the GP's computer system.[2]:84

Management, not a cure[edit | edit source]

The new guideline states that no treatments should be regarded as a cure, and that treatments are for symptom management.[2]

No graded exercise therapy[edit | edit source]

The new guideline states that graded exercise therapy or any other approach using fixed increases in physical activity or exercise should not be used.[2]

Criticism and controversies[edit | edit source]

Three month "pause"[edit | edit source]

Hours before the new ME/CFS was due to be published, NICE took the extraordinary step of halting publication as a result of several Royal Colleges, including the Royal College of Paediatrics and Child Health and the Royal College of Physicians, circumventing the guideline review process by complaining to NICE and demanding changes to the final, approved guideline.[18]

The delay was heavily criticised by guideline stakeholders including Doctors with M.E. who accused NICE of acting unlawfully, and all the national patient groups, who had not been aware of the private discussions taking place.[19]

In the UK news coverage, NICE was accused of "capitulating to vested interests" and "putting patients at risk" over the delays.[20][21] During the three month "pause" in publication, NICE invited a limited number of guideline stakeholders to a roundtable meeting, and communicated directly with a number of Royal Colleges and other stakeholders.[citation needed]

Patient court case[edit | edit source]

After NICE halted publication of the guideline in Aug 2017, a patient began a legal proceedings to challenge NICE over the delay, and find out the reasons for the delay. NICE did not respond to the publication deadline set by the patient's lawyer, but published the guideline soon after.[22][23]

Forward-ME response[edit | edit source]

Forward-ME welcomed the new guideline and highlighted the introduction of energy management as a new treatment approach in the NICE guideline, including pacing, and the significant improvements made to child safeguarding, stating that "some parents of children with ME have been subjected to inappropriate child protection orders, and threatened with the removal of their children, in the belief that the parents had caused a ‘fabricated or induced illness’."

Forward-ME started that "the recommendations on ‘Energy Management’ will also help people with LongCovid who experience Post-Exertional Malaise (PEM), many of whom have reported that ‘Graded Exercise Therapy’ worsened their condition, and their symptoms were dismissed as anxiety."
"This recommendation is a clear break from the past. Previously, people with ME were offered ‘Graded Exercise Therapy’ (GET), based on a hypothesis that they were deconditioned. NICE found the evidence for this to be poor quality, and many people with ME reported that GET caused serious harm. The new guideline on ME/CFS was due to be published in August, but NICE ‘paused’ the release following intervention from some clinicians. After a round-table with representatives from the ‘Royal Colleges’ and ME charities, NICE is now confident that the guideline can be fully implemented."[24][25]

ME Association response[edit | edit source]

[26]

Invest in ME Research response[edit | edit source]

Invest in ME Research stated that they welcomed the changes in the new guideline, but felt that undoing the harmful therapies used during the last 14 years was not enough, and the result was a fudge resulting in a guideline that could, and should, have been written in 2007.[27]

Action for ME response[edit | edit source]

ME Research UK response[edit | edit source]

ME Research UK broadly welcomed the new guideline as "a significant step in both the acceptance of ME as a physical illness and the recognition of appropriate treatment needs of those affected by the condition" and highlighted the need for further research funding, especially to better establish clear diagnostic criteria.[28]

25% ME Group response[edit | edit source]

BACME response[edit | edit source]

The British Association for CFS/ME, the largest group of doctors and health practioners working in UK ME/CFS specialist clinics, welcomed the changes in the guidelines, stating that many of its members had wanted to offer treatments others than graded exercise therapy and cognitive behavioral therapy but had been prevented from doing so due to funding being tied to guideline recommendations.[29]

Royal Colleges response[edit | edit source]

The Royal Colleges issued a joint statement stating that the guideline contained some positive changes, but that it understated "the importance of activity and exercise in the management of ME/CFS and the connection between people’s mental and physical health", in particular mentioning their view of the importance of cognitive behavioral therapy and psychological therapies.[30]

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Medical leaders sign joint statement in response to NICE guidance on ME/CFS Details 29 October 2021

We are pleased that NICE have now published their guidance for the management of ME/CFS which is a chronic, poorly understood condition and can be highly disabling and distressing. It is important that all patients with this condition are given access to the best possible services and treatments available.

The published guideline contains some positive changes, but these do not go as far as we would have liked and understate the importance of activity and exercise in the management of ME/CFS and the connection between people’s mental and physical health. We also do not think the changes represent the positive discussions that have been had with patient groups.

As in many chronic conditions, people’s mental and physical health are intrinsically linked. This guidance risks undermining the importance of these links by dismissing the potential of treatments such as Cognitive Behavioural Therapy (CBT) as of less value in alleviating symptoms than pharmacological interventions.

There is considerable disquiet in the medical profession and some patient groups about the way the data and evidence have been assessed but the important thing now is that services are commissioned in a safe and effective way that does not disadvantage any patients being treated now or in the future.

When commissioning services we would reiterate that:

Graded Exercise Therapy) as defined in the guidance is not reflective of the personalised paced exercise programmes that are currently used in the NHS and termed GET. These have provided benefit to many patients and should not be discontinued. However, we recognise that the phrase GET is unhelpful and this terminology should be dropped to allow clinicians to work with their patients in a more productive way.

CBT remains a valuable treatment for alleviating symptoms in ME/CFS and services should ensure patients have access to this and other psychological therapies.

Specialist rehabilitation medicine services and exercise medicine services regularly look after patients with ME/CFS (and also provide complex care and long-term support for very severe ME/CFS) but are not specifically recommended in the guidance. There are very few dedicated ME/CFS specialist services either in the community or hospital setting and thus if commissioners do not use specialist rehabilitation medicine services and exercise medicine services, these patients will lose out.

Commissioners must also take action to ensure training and support is available for the full range of specialist ME/CFS roles needed and are easily accessible for GPs and other clinicians across the NHS, so that this guidance can effectively be put into practice.

Many patients with ME/CFS have other conditions including chronic pain and fibromyalgia which are improved with exercise as recommended in other NICE guidance. It is important that a holistic approach is taken to ensure that other conditions do not deteriorate.

Royal College of Physicians Royal College of Physicians of Edinburgh Royal College of General Practitioners Royal College of Psychiatrists Academy of Medical Royal Colleges Faculty of Sport and Exercise Medicine Faculty of Occupational Medicine

Prof. David Tuller[edit | edit source]

Other patient groups[edit | edit source]

Physios for ME response[edit | edit source]

[31]

Doctors with M.E. response[edit | edit source]

Doctors with M.E. considers the launch of this guideline to be a watershed moment in the history of ME/CFS medical care in the UK, with implications that extend to those Long Covid (PASC) patients who also meet ME/CFS diagnostic criteria. The new guideline discards discredited psychological theories and therapies in favour of a more patient centred approach, driven by improved scientific understanding. It represents a positive and total paradigm change, uniting around the science, official disease classification and medico-legal compliance implications.

Harmful Graded Exercise Therapy is discontinued and must not be replaced with renamed or rebranded versions, which would be clinically, scientifically and legally unsustainable. Accounting for systemic exertion intolerance and post exertional symptom exacerbation is at the heart of the science and the new guideline.[32]


Individuals doctors gave different responses.

NICE Guideline revision process (2018-2021)[edit | edit source]

The public pressure from ME patients, including a petition by the ME Association, led to the decision to fully revise the guideline and which would not be concluded until around October 2020.[4][5]

NICE held a Stakeholders Engagement Workshop on 16 January 2018 and a summary of the day has been produced by the ME Association [33].

Invest in ME Research wrote to Professor Mark Baker, Centre for Guidelines Director, on January 15th 2018 asking NICE to urgently remove or add an addendum or correction for the recommendation of CBT and GET now to avoid harm to patients [34]. Prof. Baker responded that they could not remove such recommendations for CBT and GET and had to wait for the full review of the guidelines which would be due in 2020. Invest in ME wrote back on 16 January repeating that they should at least add an addendum about CBT/GET. Patient advocates have commented that the right to refuse CBT/GET treatment as stated by Prof Baker is an offer you can't refuse.[35]

An unprecedented proactive open letter to Sir Andrew Dillon was sent on January 12th 2018 by ME sufferers regarding the composition of the new guideline committee due to the history of the CFS/ME NICE guideline and committee and an Appeal to NICE concerning the Guideline Committee for ME/CFS petition was also launched to support this.[36][37] ME sufferers led by Graham McPhee from MEAnalysis produced a video to accompany the letter and petition [38].

An unprecedented third petition was launched to NICE Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW which asked that NICE immediately remove CBT/GET from the guidelines in the face of evidence of harm amounts to medical abuse and violation of human rights.[39]

In a BBC Newsround article it was again stated by patient groups that the guideline for CBT/GET should be withdrawn immediately but this was refuted by a statement by the "country's leading ME researchers" that they should not. It was later clarified that many of the proponents were involved in the PACE trial. The article stated that in 2018 "NICE admits there is "controversy" around existing treatments" [40].

A scoping workshop was undertaken on May 25th, 2018. It was announced that the new Chair of the GDG would be Dr Peter Barry and the Vice Chair Ilora Finlay. A draft scope consultation was also produced [41]. The name of the illness was changed from CFS/ME to ME/CFS and the new guideline was called Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management.[1] Some stakeholders were not notified until the night before of the workshop.[42] Others raised some concerns with the stakeholder workshop.[43]

Positive Health magazine reported on What Can We Expect from the Current Review of NICE Guideline CG53 and concluded that the biopsychosocial (psychiatric) model proponents would still try to influence the guidelines to retain the status quo.[44]

NICE guidelines NG206 published 2021[edit | edit source]

After a series of delays through the NICE guidelines review, including a three month "pause" in publication, the final Myalgic encephalomyelitis (or encephalopathy)/Chronic fatigue syndrome: diagnosis and management guidelines, known as NG206, were published on October 2021.[2]

NICE Guidelines for CFS/ME - CG53 (2007)[edit | edit source]

The NICE guideline for CFS/ME (CG53) for the diagnosis and management of chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) were published in August 2007. They are used by the NHS and other medical professionals in the UK for diagnosing and treating CFS/ME.

Authors[edit | edit source]

The CFS/ME guideline development group consisted of the following members: Richard Baker, Jessica Bavinton, Esther Crawley, Tony Downes, Richard Eddleston, Ute Elliot, Richard Grünewald, William Hamilton, Judith Harding, Frederick Nye, Amanda O'Donovan, Alastair Santhouse, Julia Smedley]], David Vickers, Gillian Walsh, Carol Wilson, Philip Wood, Gary Britton, Stefanie Kuntze, Elizabeth Shaw, Nancy Turnbull, and Tanya Harrison.[45]

NICE Definition (2007-Oct 2021)[edit | edit source]

Healthcare professionals should consider the possibility of CFS/ME if a person has:

  • fatigue with all of the following features:
    • new or had a specific onset (that is, it is not lifelong)
    • persistent and/or recurrent
    • unexplained by other conditions
    • has resulted in a substantial reduction in activity level
    • characterised by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days)

and

Healthcare professionals should be aware that the symptoms of CFS/ME fluctuate in severity and may change in nature over time.

Signs and symptoms that can be caused by other serious conditions (‘red flags’) should not be attributed to CFS/ME without consideration of alternative diagnoses or comorbidities. In particular, the following features should be investigated:

  • localising/focal neurological signs
  • signs and symptoms of inflammatory arthritis or connective tissue disease
  • signs and symptoms of cardiorespiratory disease
  • significant weight loss
  • sleep apnea
  • clinically significant lymphadenopathy

A diagnosis should be made after other possible diagnoses have been excluded and the symptoms have persisted for:

  • 4 months in an adult
  • 3 months in a child or young person; the diagnosis should be made or confirmed by a paediatrician

The diagnosis of CFS/ME should be reconsidered if none of the following key features are present:

Criticism and controversy[edit | edit source]

Charities and patient groups condemned the guidelines as "unfit for purpose".

The submissions were from:

Invest in ME Submission[edit | edit source]

ME Association Submission[edit | edit source]

25 Percent ME Group Submission[edit | edit source]

Tymes Trust Submission[edit | edit source]

Tymes Trust November 2006 Submission

Action for ME Submission[edit | edit source]

Agreed statement from all ME Charities[edit | edit source]

An agreed statement was also put out by all ME Charities.[47]

Criticism of the York Review by Professor Hooper[edit | edit source]

The NICE guidelines were based on the evidence presented by the 2005 York Review, produced by the Centre for Reviews and Dissemination (CRD). Prof. Malcolm Hooper submitted written criticism of the York Review to UK Parliament, stating that this supposedly independent review was strongly influenced by the Wessely school's biopsychosocial model. Hooper & Reid published an analysis of the failings in the York Review.

Professor Hooper also submitted written evidence to the House of Commons Select Committee on NICE and the CFS/ME guidelines.[48]

MEActionUK Submission and Reports[edit | edit source]

MEActionUK published their Concerns and Submission about the draft NICE guidelines in October 2006.[49] MEActionUK also published comment on the final draft of the August 2007 guidelines.[50] The failure by NICE to fulfil its remit and the biomedical evidence that NICE ignored in its production is also investigated and reported on.[51][52] MEAction UK have published a number of other reports into the criticism of the NICE guidelines on their website.

NICE Judicial Review Court Case (2009)[edit | edit source]

In 2009, two ME patients launched a court case against NICE and against the newly-published NICE guidelines, leading to a judicial review which was not successful.[53][54]

Move to static list (2013)[edit | edit source]

On September 2013 NICE placed the CFS/ME guidelines CG53 on a static list and confirmed they won't be reviewing them,[55] this then led to protests from patients, researchers and clinicians; and a guideline review was announced in September 2017. There were considerable concerns raised on 2013.

The Countess of Mar and Forward-ME said "We express our extreme concern over this proposal and strongly feel that the guideline must remain on the active list for the following reasons. Medical and scientific advances in relation to ME and CFS are taking place very rapidly." This was a joint letter was signed by a number of ME Charities. [56]

The ME Association opposed the plan to place it on static list and wrote a submission with four reasons including that "Along with most other ME/CFS charities, and people with ME/CFS, we have been unable to endorse the current NICE guideline." [57]

Patients and patient advocacy groups are not in favor of the NICE guidelines and on June 25th 2014 the Forward-ME Group met with Prof Mark Baker, Director of the Centre for Clinical Practice at the National Institute for Health and Clinical Excellence (NICE)]. Professor Baker that the ME/CFS Guideline did not meet patient needs nor those of NICE. He said the Guideline did not promote innovation and only a "passive" intervention such as CBT and Graded Exercise. "There was not much of an evidence base to go on, and in NICE it was evidence that drove guidance."[58]

Doctor Speedy weighs in with Is it NICE guidelines or NONSENSE guidelines? and the ME Association's Dr. Charles Shepherd pointed out during a meeting with Dr. Martin McShane of NHS England "that graded exercise therapy was causing harm to patients and that if a drug was causing harm, guidelines would be reviewed immediately."[59]

A FOI request to NICE about the US developments was submitted to NICE in 2016 and they responded to it in 2016 in which they dismissed foreign work on ME/CFS.[60]

NICE 10 year surveillance (2017)[edit | edit source]

In June 2017 stakeholders were advised that NICE would consider reviewing the guidelines.[61] In July NICE stated they decided not to review the guidelines.[62]

A petition to NICE, The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision, gathered over 15,000 signatures.[63]

All patient stakeholders requested that guidelines be reviewed.

  • The MEAction Network's response to NICE stated the NICE guidelines be reviewed and "Given the context of this discrimination, we ask that the updated NICE guidelines be made clearer to account for the limitations of the evidence, patient reports of long term relapse following graded exercise, and the importance of genuine patient choice without reprisal."[64]
  • Forward-ME's response to NICE stated the NICE guidelines be reviewedand included "Because the current guideline directs patients squarely towards behavioral management, it clearly does obstruct patients’ access to biological testing, treatment and support. To avoid this ethical violation, we request that the guideline be revised to present a truthful, neutral picture of the current debate about the nature and management of CFS/ME."[66]
  • Action for ME stated the NICE guidelines be reviewed and "strongly disagrees with the proposal not to update the guideline for the following reasons...There is not, at the present time, a conclusive evidence base for treatments for CFS/M.E., including those recommended in the guideline, such as CBT and/or GET."[68]
  • Tymes Trust's response to NICE stated the NICE guidelines be reviewed.[69]

The ME Association described the public response to its petition as "The biggest expression of no confidence in a NICE guideline ever recorded".[5]

A letter was also sent to the Chief Executive of NICE Sir Andrew Dillon.[70]

Prof. David Tuller in his investigation stated NICE did not disclose the names of the topic experts to the Countess of Mar and the ME Association and himself were also awaiting for a response to the names.[71]

A letter to the Chief Medical Officer was sent by the MEA.[72]

Dr Charles Shepherd of the ME Association wrote to NICE in July 2017 to ask for further information on the team that decided to not review the guidelines but NICE refused.[73] He followed up with another email in August but this also did not respond to the request asked and stated" remain very disappointed that NICE is unwilling to release the names of members of a group who have been involved in producing what is a very unpopular conclusion regarding the possible updating of the NICE guideline on ME/CFS" and correspondence continued[74]

Dr Diane O'Leary, of the Kennedy Institute of Ethics at Georgetown University, Washington DC, said at the Forward-ME parliamentary meeting that the "Guideline as it stands is unethical."[75]

Dr Tuller's own FOI request was rejected on 31 July 2017 for the names of the experts.[76]

Dr David Tuller also wrote to the NICE Chief Executive, Sir Andrew Dillon, with 15 questions of which none were responded to.[77]

Dr David Tuller submitted an additional FOI request for the NICE Topic Expert Reports which were provided to him. Tuller examined these and said " this set of comments is the best NICE could drum up in seeking external guidance for this critical review process is deeply worrying."[78]

Due to the shock that the NICE guidelines were not reviewed, MEAction supporters raised a parliamentary petition called an Early Day Motion (271) in September to put further pressure on NICE.[79]

On September 20, 2017, NICE announced that a full review would take place, effectively overturning the previous expert advice not to review the guideline.[80][81]

The Times newspaper reported on September 24th it as Mutiny by ME sufferers forces a climbdown on exercise treatment and the article described the patient revolt over the reassessment of NICE Guidelines was over the validity of the PACE trial.[82][83]

Prof. David Tuller reported on it Trial By Error: NICE Rejects Current Guidance, Plans "Full Update".[84]

Jennifer Brea was interviewed in The Times for the Unrest documentary in which she criticized the British approach on CBT/GET and the NICE guidelines in the UK as “not an easy place to have ME”.[85]The Telegraph quoted Jennifer Brea saying, in reference to the NICE guidelines, "I hope the UK will look at the science and update the guidelines."[86]

Prof Tuller also wrote another letter to Sir Andrew Dillon questioning why CFS/ME was also stated under Improving Access to Psychological Therapies (IAPT) and furthermore in another NICE guideline Suspected Neurological Conditions where CFS/ME was wrongly categorised as medically unexplained symptoms.[87]

Learn more[edit | edit source]

NICE guideline [NG206] (2021-present)

See also[edit | edit source]

References[edit | edit source]

  1. 1.01.1 "Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management GID-NG10091". National Institute for Health and Care Excellence. June 27, 2018.
  2. 2.02.12.22.32.42.52.62.7 "Myalgic encephalomyelitis (or encephalopathy)/Chronic fatigue syndrome: diagnosis and management NICE guideline [NG206]". National Institute for Health and Care Excellence. October 29, 2021.
  3. "NICE | The National Institute for Health and Care Excellence". National Institute for Health and Care Excellence. Retrieved January 13, 2019.
  4. 4.04.14.2 ME Association (July 21, 2017). "MRA Submission to NICE re: Guideline Revise | 21 July 2017" (PDF).
  5. 5.05.15.2 ME Association (July 26, 2017). "ME Association petition represents biggest expression of no confidence in a NICE guideline ever recorded". Retrieved October 30, 2021.
  6. "Forward-ME Meeting with Professor Mark Baker, Director of Guidelines, NICE | 04 December 2017 | The ME Association". The ME Association. December 4, 2017. Retrieved October 30, 2021.
  7. Institute of Medicine (2015), Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness, Washington, DC: The National Academies Press
  8. Smith ME, Nelson HD, Haney E, Pappas M, Daeges M, Wasson N, McDonagh M (December 2014). "Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome No. 219". Evidence Report/Technology Assessment. Agency for Healthcare Research and Quality (US): 1–433. doi:10.23970/AHRQEPCERTA219. PMID 30313001.
  9. Carruthers, BM; van de Sande, MI; De Meirleir, KL; Klimas, NG; Broderick, G; Mitchell, T; Staines, D; Powles, ACP; Speight, N; Vallings, R; Bateman, L; Bell, DS; Carlo-Stella, N; Chia, J; Darragh, A; Gerken, A; Jo, D; Lewis, DP; Light, AR; Light, KC; Marshall-Gradisnik, S; McLaren-Howard, J; Mena, I; Miwa, K; Murovska, M; Stevens, SR (2012), Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners (PDF), ISBN 978-0-9739335-3-6
  10. 10.010.1 "IOM 2015 Diagnostic Criteria | Myalgic Encephalomyelitis/Chronic Fatigue Syndrome". Centers for Disease Control. January 27, 2021. Retrieved February 25, 2021.
  11. mayfly (April 3, 2019). "Forward ME and Oxford Brookes University Announce Results of Patient Survey on CBT and GET in ME/CFS | 03 April 2019 | The ME Association". Retrieved November 6, 2021.
  12. "ME/CFS Illness Management Survey Results - "No decisions about me without me" Part 1" (PDF). meassociation.org. ME Association. May 2015.
  13. 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.
  14. CureME (February 6, 2019). "We're delighted to announce that our Research Fellow & Biobank Coordinator Caroline Kingdon has also been appointed to the NICE #MECFS Guideline Committee.

    While this is yet to be announced on NICE's website, we are sharing the news here now as meetings are beginning.
    #pwME pic.twitter.com/OH9JPTMARo pic"
    . Twitter. Retrieved February 6, 2019.
  15. NICE (October 16, 2018). "Committee member list | NICE CG53 CFS/ME guidance update". nice.org.uk. Retrieved October 20, 2018.
  16. Shepherd, Charles (November 9, 2018). "ME Association Statement re: NICE ME/CFS Guideline Review and Committee Appointments | 09 November 2018". The ME Association. Retrieved November 15, 2018.
  17. NICE (May 24, 2018). "Stakeholder Engagement Meeting Interim Findings | NICE CFS/ME guidelines review". www.nice.org.uk.
  18. Grover, Natalie (August 17, 2021). "UK health standards body delays new ME guidance in therapy row". The Guardian.
  19. https://www.senseaboutscience.org.uk/doctors-with-m-e-medical-unlawfulness-and-the-nice-me-cfs-guideline-delay/
  20. https://www.independent.co.uk/news/health/nice-chronic-fatigue-exercise-therapy-covid-b1904127.html
  21. https://www.thetimes.co.uk/article/delays-to-me-guidelines-are-putting-patients-at-risk-s5bzfhxjl
  22. https://www.thecanary.co/uk/analysis/2021/10/02/nice-is-facing-a-legal-challenge-over-its-me-guidelines-delay/?
  23. https://www.twitter.com/PeterTodd_/status/1443887167055581188
  24. Forward-ME (October 29, 2021). "NEW NICE GUIDELINES ON ME: FORWARD-ME STATEMENT & MEDIA SUPPORT - Oct 29th 2021". Retrieved October 29, 2021.
  25. Forward-ME (October 29, 2021). "NICE Publishes new Guideline on ME/CFS*, driving major improvements in care". Retrieved October 29, 2021. no-break space character in |title= at position 49 (help)
  26. The ME Association (October 29, 2021). "The new NICE guideline on ME/CFS is published!".
  27. Invest in ME Research (October 29, 2021). "NICE GUIDELINES - TAKING US FORWARD TO 2007".
  28. ME Research UK (October 29, 2021). "Our response to the updated NICE guideline".
  29. British Association for CFS/ME (October 2021). "Press Statement NICE Guideline publication Oct 2021".
  30. "Royal Colleges Joint Statement". Royal College of Physicians. October 29, 2021.
  31. Physios for ME (October 2021). "NICE Publish New Guidelines".
  32. Doctors with M.E. (November 1, 2021). "NICE 2021: A Triumph of Science over Discrimination".
  33. "Reviewing the NICE guideline for ME/CFS: The Stakeholders Engagement Workshop – A Report by Dr Charles Shepherd". [[The ME Association[[. January 17, 2018. Retrieved October 30, 2021.
  34. Invest in ME Research (January 2018). "Correspondence with Professor Mark Baker - Centre for Guidelines Director, National Institute for Health and Care Excellence".
  35. Spoonseeker (January 28, 2018). "An Offer You Can't Refuse". spoonseekerdotcom. Retrieved October 30, 2021.
  36. "Graham's finished letter to NICE January 2018". Science for ME. January 2018.
  37. The ME Association (2017). "The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision". Change.org. Retrieved October 30, 2021.
  38. MEAnalysis (January 14, 2018). "The PACE trial: A Short Explanation Part 3: Why It Matters". YouTube.
  39. Brown, Robin (2017). "NICE: Stop Harming ME/CFS patients - take CBT and GET out of the CFS guidelines now". Change.org. Retrieved October 30, 2021.
  40. "Chronic fatigue syndrome treatment 'should be withdrawn'". BBC Newsbeat. May 8, 2018.
  41. "Guideline scope (draft)". National Institute for Health and Care Excellence. 2018.
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NICE guidelines Clinical guidelines used in the UK.

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.

cognition Thought processes, including attention, reasoning, and memory.

post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive 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.

NICE guidelines Clinical guidelines used in the UK.

post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive 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.

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.

holistic Treating mind, body and spirit together, with the aim of achieving wellness and good health. May be within modern medicine or alternative / traditional medicine.

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.

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.

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.

The information provided at this site is not intended to diagnose or treat any illness.
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