> "Earlier results from the PACE (adaptive pacing, graded activity, and cognitive behaviour therapy—a randomised evaluation) trial, published in the Lancet in 2011, showed that in a group of 641 patients cognitive behavioural therapy (CBT) and graded exercise therapy (GET) were of more benefit at 52 weeks to people with chronic fatigue syndrome than adaptive pacing therapy (APT) and usual specialist medical care.2"
The BMJ's description of the PACE trial is incorrect [1,2]. Usual specialist medical care (SMC) was used as a control intervention in the PACE trial which included an SMC-alone control group, however, CBT and GET were administered concurrently and in addition to SMC in the other intervention groups. There were modest additional benefits when CBT or GET were added to SMC, but for self-report measures only.
When using objectively measured outcomes there were no improvements after additional treatment with CBT, and no clinically useful improvements after additional treatment with GET. i.e. there were no clinically useful improvements in objectively measured physical disability (six minute walk test), physical fitness (step test), employment rates, welfare benefit claims or private insurance claims, after treatment with CBT or GET.
> "In GET the patient undertakes a personalised and gradually increasing exercise programme delivered by a physiotherapist, whereas in APT the patient adapts their activity levels to the amount of energy they have."
The BMJ's description of GET is simplistic and misleading; The therapists handbook for GET in the PACE trial instructed therapists to 'adapt' the therapy if the patient experienced a "relapse" in symptoms, in order to avoid "difficulties" [3]. Therapists were instructed to "adapt the plan immediately to avoid difficulties." Such an adaptation, to take account of fluctuating symptoms, is widely known as "pacing". So GET, as administered in the PACE trial, included elements of pacing, in order to avoid causing 'relapses' in the illness.
References:
1. Torjesen I. (2015) Tackling fears about exercise is important for ME treatment, analysis indicates. BMJ 350:h227
2. White PD, Goldsmith KA, Johnson AL et al. (2011) Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377:823-36.
3. Bavinton J, Darbishire L, White PD. (2004) PACE; Manual for Therapists; Graded Exercise Therapy for CFS/ME; FINAL TRIAL VERSION: Version 7. (Internet) (Last accessed 16 Jan 2015) [ http://www.pacetrial.org/docs/get-therapist-manual.pdf ]
Rapid Response:
> "Earlier results from the PACE (adaptive pacing, graded activity, and cognitive behaviour therapy—a randomised evaluation) trial, published in the Lancet in 2011, showed that in a group of 641 patients cognitive behavioural therapy (CBT) and graded exercise therapy (GET) were of more benefit at 52 weeks to people with chronic fatigue syndrome than adaptive pacing therapy (APT) and usual specialist medical care.2"
The BMJ's description of the PACE trial is incorrect [1,2]. Usual specialist medical care (SMC) was used as a control intervention in the PACE trial which included an SMC-alone control group, however, CBT and GET were administered concurrently and in addition to SMC in the other intervention groups. There were modest additional benefits when CBT or GET were added to SMC, but for self-report measures only.
When using objectively measured outcomes there were no improvements after additional treatment with CBT, and no clinically useful improvements after additional treatment with GET. i.e. there were no clinically useful improvements in objectively measured physical disability (six minute walk test), physical fitness (step test), employment rates, welfare benefit claims or private insurance claims, after treatment with CBT or GET.
> "In GET the patient undertakes a personalised and gradually increasing exercise programme delivered by a physiotherapist, whereas in APT the patient adapts their activity levels to the amount of energy they have."
The BMJ's description of GET is simplistic and misleading; The therapists handbook for GET in the PACE trial instructed therapists to 'adapt' the therapy if the patient experienced a "relapse" in symptoms, in order to avoid "difficulties" [3]. Therapists were instructed to "adapt the plan immediately to avoid difficulties." Such an adaptation, to take account of fluctuating symptoms, is widely known as "pacing". So GET, as administered in the PACE trial, included elements of pacing, in order to avoid causing 'relapses' in the illness.
References:
1. Torjesen I. (2015) Tackling fears about exercise is important for ME treatment, analysis indicates. BMJ 350:h227
2. White PD, Goldsmith KA, Johnson AL et al. (2011) Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377:823-36.
3. Bavinton J, Darbishire L, White PD. (2004) PACE; Manual for Therapists; Graded Exercise Therapy for CFS/ME; FINAL TRIAL VERSION: Version 7. (Internet) (Last accessed 16 Jan 2015) [ http://www.pacetrial.org/docs/get-therapist-manual.pdf ]
Competing interests: No competing interests