- Jul 2018
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europepmc.org europepmc.org
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On 2013 Oct 29, Tom Kindlon commented:
Pacing is another therapeutic option available for chronic fatigue syndrome
In this article, the authors state that there is substantial evidence for two treatments for chronic fatigue syndrome (CFS): cognitive behaviour therapy (CBT) and graded exercise therapy (GET). However, the findings rely largely on a limited number of subjective measures: this is significant given trials of these therapies are effectively non-blinded and thus changes may be due to non-specific factors such as therapist attention and other reporting biases.
For example, the review highlighted the positive results for CBT and GET reported in a large randomized controlled trial (RCT).<sup>1</sup> However, on the only objective measure reported in that paper, the six minute walking test, there was no significant difference between the CBT group and controls. The participants who completed GET did improve somewhat (35 m more than controls); however 379 m remains a very poor result given age- and gender-matched population norms predict around 640 m.<sup>2</sup> By comparison, a review reported an average distance of 393 m for 1083 patients with various cardiopulmonary disorders.<sup>3</sup>
Comparable results were found in a review of three RCTs of CBT interventions aimed at increasing activity. While participants recorded lower fatigue scores compared to controls, no difference emerged when activity was objectively assessed.<sup>4</sup> Apart from some people simply deteriorating, two other explanations are possible for these somewhat paradoxical results. Participants may not have consistently performed the scheduled activities and exercises in the protocol. Alternatively, participants may be reprioritizing their activities, substituting those in the protocol for other activities in their daily lives.<sup>2</sup> Compliance has generally not been recorded in trials but both explanations are plausible given that post-exertional exacerbation of symptoms is a core feature of CFS.
More concerning, various patient surveys have noted high percentages reporting becoming worse following CBT (mean: 20%, n=1805) and GET (mean: 51%, n=4338).<sup>2</sup> By comparison, only 2.6% (n=5894) reported such an adverse effect with pacing. The sample size indicates that many people with CFS have utilised pacing. Patient preference is increasingly recognised as important in clinical practice and pacing offers an alternative to CBT and GET that, among other things, is potentially safer.<sup>2,5</sup>
Pacing can be symptom or time-contingent, or a combination of both.<sup>6</sup> The aim is simply to remain as active as possible while avoiding over-exertion. This contrasts with CBT and GET where patients are encouraged to tolerate post-exertional exacerbations. Although not as widely tested as CBT and GET, there is some evidence from RCTs for pacing’s efficacy.<sup>6</sup>
References:
1 White PD, Goldsmith KA, Johnson AL, et al.; PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377(9768):823-836.
2 Kindlon T. Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Bulletin of IACFS/ME. 2011;19(2):59-111. http://iacfsme.org/BULLETINFALL2011/Fall2011KindlonHarmsPaperABSTRACT/tabid/501/Default.aspx (Last accessed: November 11, 2012)
3 Ross RM, Murthy JN, Wollak ID, Jackson AS. The six minute walk test accurately estimates mean peak oxygen uptake. BMC Pulm Med. 2010 May 26;10:31.
4 Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G. How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity. Psychol Med. 2010;40(8):1281-7.
5 Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572
6 Goudsmit EM, Nijs
This comment, imported by Hypothesis from PubMed Commons, is licensed under CC BY.
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- Feb 2018
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www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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On 2013 Oct 29, Tom Kindlon commented:
Pacing is another therapeutic option available for chronic fatigue syndrome
In this article, the authors state that there is substantial evidence for two treatments for chronic fatigue syndrome (CFS): cognitive behaviour therapy (CBT) and graded exercise therapy (GET). However, the findings rely largely on a limited number of subjective measures: this is significant given trials of these therapies are effectively non-blinded and thus changes may be due to non-specific factors such as therapist attention and other reporting biases.
For example, the review highlighted the positive results for CBT and GET reported in a large randomized controlled trial (RCT).<sup>1</sup> However, on the only objective measure reported in that paper, the six minute walking test, there was no significant difference between the CBT group and controls. The participants who completed GET did improve somewhat (35 m more than controls); however 379 m remains a very poor result given age- and gender-matched population norms predict around 640 m.<sup>2</sup> By comparison, a review reported an average distance of 393 m for 1083 patients with various cardiopulmonary disorders.<sup>3</sup>
Comparable results were found in a review of three RCTs of CBT interventions aimed at increasing activity. While participants recorded lower fatigue scores compared to controls, no difference emerged when activity was objectively assessed.<sup>4</sup> Apart from some people simply deteriorating, two other explanations are possible for these somewhat paradoxical results. Participants may not have consistently performed the scheduled activities and exercises in the protocol. Alternatively, participants may be reprioritizing their activities, substituting those in the protocol for other activities in their daily lives.<sup>2</sup> Compliance has generally not been recorded in trials but both explanations are plausible given that post-exertional exacerbation of symptoms is a core feature of CFS.
More concerning, various patient surveys have noted high percentages reporting becoming worse following CBT (mean: 20%, n=1805) and GET (mean: 51%, n=4338).<sup>2</sup> By comparison, only 2.6% (n=5894) reported such an adverse effect with pacing. The sample size indicates that many people with CFS have utilised pacing. Patient preference is increasingly recognised as important in clinical practice and pacing offers an alternative to CBT and GET that, among other things, is potentially safer.<sup>2,5</sup>
Pacing can be symptom or time-contingent, or a combination of both.<sup>6</sup> The aim is simply to remain as active as possible while avoiding over-exertion. This contrasts with CBT and GET where patients are encouraged to tolerate post-exertional exacerbations. Although not as widely tested as CBT and GET, there is some evidence from RCTs for pacing’s efficacy.<sup>6</sup>
References:
1 White PD, Goldsmith KA, Johnson AL, et al.; PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377(9768):823-836.
2 Kindlon T. Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Bulletin of IACFS/ME. 2011;19(2):59-111. http://iacfsme.org/BULLETINFALL2011/Fall2011KindlonHarmsPaperABSTRACT/tabid/501/Default.aspx (Last accessed: November 11, 2012)
3 Ross RM, Murthy JN, Wollak ID, Jackson AS. The six minute walk test accurately estimates mean peak oxygen uptake. BMC Pulm Med. 2010 May 26;10:31.
4 Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G. How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity. Psychol Med. 2010;40(8):1281-7.
5 Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572
6 Goudsmit EM, Nijs
This comment, imported by Hypothesis from PubMed Commons, is licensed under CC BY.
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