Intended for healthcare professionals

Rapid response to:


Commentary: Heading for a therapeutic stalemate

BMJ 2011; 342 doi: (Published 22 June 2011) Cite this as: BMJ 2011;342:d3774

Rapid Response:

Response to: Heading for a therapeutic stalemate

One of the reasons many patients with myalgic
encephalomyelitis/chronic fatigue syndrome (ME/CFS) may not try cognitive
behavioural therapy (CBT) or graded exercise therapy (GET) is because they
are not convinced they have been "shown to be effective and safe"[1].

Randomised controlled trials (RCTs) have tended to use subjective
outcome measures which can be subject to various response biases; results
may differ dramatically when objective measures are employed. For example,
in the PACE Trial, a mean 6-minute walking distance of 379m following GET
is far from impressive; while the small improvement obtained following
("effective") CBT was no different to the change for the remaining two
trial arms[2].

Regarding safety claims: with pharmacological agents, systems such as
the yellow card scheme exist to collate adverse reactions; no similar
structures exist for non-pharmacological interventions such as CBT and
GET. Thus authorities may believe that no harms have occurred in clinical
practice when in fact, in patient surveys, a relatively high percentage of
ME/CFS patients have reported being made worse by rehabilitative
approaches, particularly GET[3,4].

Given all this, the fact that reporting of harms has been poor in
previous RCTs and the recognised abnormal response to exercise in the
condition, ME/CFS patients should be free to refuse CBT and GET without


1. Groves T. Heading for a therapeutic stalemate BMJ 2011; 342:d3774
doi: 10.1136/bmj.d3774

2. Kindlon T. The PACE trial in chronic fatigue syndrome. Lancet.

3. Kindlon T, Goudsmit EM. Graded exercise for chronic fatigue
syndrome: too soon to dismiss reports of adverse reactions. J Rehabil Med.

4. Twisk FN, Maes M. 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 Endocrinol Lett 2009;30:284-299

5. Chambers D, Bagnall AM, Hempel S, Forbes C. Interventions for the
treatment, management and rehabilitation of patients with chronic fatigue
syndrome/myalgic encephalomyelitis: an updated systematic review. J R Soc
Med. 2006;99:506-20

Competing interests: No competing interests

27 June 2011
Tom Kindlon
Information Officer (voluntary position)
Irish ME/CFS Association