The last fear avoidance related papers I read had limited design and biased assumptions. There is also no objective evidence that the proposed "treatments" (CBT/GET) results in sustained increases in total activity levels anyway.
Even better:
http://www.cfids-cab.org/rc/Wiborg.pdf (done by the hardcore CBT/GET group in the Netherlands) showed that CBT with GET as a core component (following the manual at
https://listserv.nodak.edu/cgi-bin/wa.exe?A2=ind1009C&L=CO-CURE&P=R1774&I=-3 ) in three of their previous trials was completely ineffective at increasing objective physical levels as measured by actometers.
But questionnaire scores said everyone felt so much less fatigued! So CBT/GET must work, right?
John H Wolfe - the above study, and the three studies which it reviews, are an excellent illustration of 1) the ineffectiveness of CBT/GET when outcomes are measured objectively, and 2) the way that proponents of these treatments will go to great lengths to cover up and spin the results.
First, negative actometer results were not mentioned in the initial three studies - only positive results from questionnaires. This is a fundamental academic dishonesty, yet it is pretty much par for the course when it comes to CBT/GET research in ME/CFS.
Second, it demonstrates that questionnaires are not a reliable measurement of physical functioning, yet in many cases, these questionnaires are the only measurements used. Likely the Dutch study was forced to use/publish them eventually, whereas the British researchers are free to stick to subjective measurements.
Thirdly, it demonstrates why abstracts and reviews absolutely cannot be trusted. If you conduct several studies of a therapy and the objective measurement shows no improvement, how would you summarize the results? I'd go for something like "CBT/GET is ineffective at increasing the sustainable activity levels of CFS patients".
Yet somehow they end up with "The effect of CBT on fatigue in CFS is not mediated by a persistent increase in physical activity." Okay, well I guess that's sort of true, if we assume that the questionnaires are a better measurement of fatigue than the activity levels are. So let's read the Discussion - maybe there's a better explanation in that part of the paper: "In the light of these findings, changing illness related cognitions seems to play a more crucial role in CBT for CFS than an increase in physical activity."
So if increased physical capacity didn't make the patients do better on questionnaires, then it must be their changes in thinking! It wasn't really the activity after all, just becoming more positive thinkers. Of course, this doesn't solve the problem that the patients for whom CBT/GET was a "success" are still just as incapacitated as they were before treatment. And it relies on the rather baffling assumption that getting better questionnaire answers from patients is more relevant than getting them to a higher level of physical functioning.
This sort of spin illustrates the crux of the CBT/GET "success" issue: do you want to give better answers on questionnaires, or do you want to be more functional? Because CBT/GET has been extensively demonstrated (by its own proponents) as only doing the former, and never the latter.