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Controversy over exercise therapy for CFS: key lessons for clinicians & academics (Mitchell, 2017)

Dolphin

Senior Member
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17,567
Considering it was in the British Journal of Psychiatry, that comment was not as bad as I expected. I found the tone irritating when I first read it, and still a bit did on a re-read, but less so.

Small correction: this isn't the main British Journal of Psychiatry:
Published bimonthly by The Royal College of Psychiatrists, BJPsych Advances offers a distillation of current clinical knowledge, written by expert clinicians to meet the CPD needs of consultant psychiatrists.
 

Dolphin

Senior Member
Messages
17,567
It was pleasing to see some of the criticisms of the pace trial mentioned. This is quite a change from say editorials (as opposed to news pieces) that have been published in the BMJ over the last 20 years.

Anyway I'll highlight a few more little points for what they are worth:
Chronic fatigue syndrome (CFS) is a recognised but poorly understood condition for which there is no single recognised cause. The hallmark is persistent unremitting fatigue lasting at least 6 months and causing significant disability such as interference with work and emotional distress.
Not a great definition of CFS. But then the Oxford criteria were used in I think 5 of the 8 studies in the Cochrane review.

Although there is often no clear medical explanation for established CFS, it is unclear whether this is due to failure of medical science, shortcomings in proffered medical investigations or the absence of medical underlying contributory factors.
The last bit is frustrating.
 

Dolphin

Senior Member
Messages
17,567
The evidence that exercise therapy does any harm is slim, but acceptability is a problem. In CFS, by definition, fatigue and/or depression directly limit involvement in and motivation for exercise therapy.
It is good that their acceptability was brought up, it rarely seems to be.

But it is frustrating that the depression and a lack of motivation are listed as 2 of the 3 reasons limiting involvement in exercise therapy in CFS.
 
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Dolphin

Senior Member
Messages
17,567
Given their propensity to reply to articles, I wouldn't be surprised if one or more of the PACE trial investigators send in reply. It would be good if people try to keep an eye on it as we could reply to any reply from them.
 

Dolphin

Senior Member
Messages
17,567
Some patients struggle with GET, but many object to the offer of CBT, particularly when it is given in a mental health setting as an alternative (rather than an adjunct) to medical care.
It was interesting to see this point being raised. While I'm not sure that the form of CBT used in CFS is appropriate for that many, this distinction (CBT or GET being adjunctive therapy versus primary therapy) is rarely mentioned except by patients.
 

Dolphin

Senior Member
Messages
17,567
Exercise therapy was typically 3–5 times per week (but for as little as 5–15 minutes per session) over a course of 12–26 weeks. The majority of the studies focused on aerobic exercise reviewed by qualified therapists. Participants were usually asked to perform self-monitoring using the Borg Scale or an exercise diary, but no studies used wearable fitness monitors (such as Fitbit®), which would have been genuinely useful for monitoring activity and sleep over a 24-hour cycle.
Good to see this point being raised.
 

Dolphin

Senior Member
Messages
17,567
Regarding drop-out rates, the Cochrane review reported that the pooled relative risk for drop-out was 1.63 (95% CI 0.77–3.43), suggesting that dropout was a problem with GET, although it did not reach statistical significance. To understand this further it is necessary to refer to raw numbers in each study. For example, in the PACE study 136 of the 160 assigned to GET were adequately treated and 10 dropped out once treatment was underway, as compared with 142 of the 160 assigned to specialist medical care alone (14 dropped out of this arm).
Interesting to see the point raised in the 1st sentence. However the numbers he gives don't suggest any increased rate of dropouts with GET.
 

Dolphin

Senior Member
Messages
17,567
In an odd move, the day before the release, the PACE authors released a re-analysis of their own data (Goldsmith 2016). This appeared to be a late response to criticism of deviation from their original protocol method, namely, that they used bimodal and dichotomous scoring rather than continuous and/or Likert scoring.

Despite these wide criticisms, re-analysis of the PACE primary data appears to show largely the same findings (which will satisfy advocates of PACE), but at a much lower magnitude of effect (which will satisfy detractors of PACE).
It's a pity he doesn't give the improvement rates reported in the Lancet and then the revised improvement rates, especially given these were the primary outcome measures.
 

Dolphin

Senior Member
Messages
17,567
In short, this Cochrane review shows that CFS symptoms improve with exercise therapy, but not how many patients recover or how many can function day to day or even how many feel better. It is useful therefore to note that objective metrics from the 6-minute walking test data were made public in the raw data released by White et al in 2016 (Fig. 1). Results show that there appears to be a very disappointing baseline 6-minute walking ability in all groups (i.e. before treatment) and a rather disappointing increase in all groups after treatment, although this is actually statistically significant (but still very modest) for those receiving GET.
Good to see it recognised that the improvement with GET was relatively modest.
 
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2,125
Had not heard of the Borg Scale of Perceived exertion before.........(will resist the urge to add Star Trek or tennis connotations).
https://www.hsph.harvard.edu/nutritionsource/borg-scale/

"One way to gauge how hard you are exercising is to use the Borg Scale of Perceived Exertion. The Borg Scale takes into account your fitness level: It matches how hard you feel you are working with numbers from 6 to 20; thus, it is a “relative” scale. The scale starts with “no feeling of exertion,” which rates a 6, and ends with “very, very hard,” which rates a 20. Moderate activities register 11 to 14 on the Borg scale (“fairly light” to “somewhat hard”), while vigorous activities usually rate a 15 or higher (“hard” to “very, very hard”). Dr. Gunnar Borg, who created the scale, set it to run from 6 to 20 as a simple way to estimate heart rate—multiplying the Borg score by 10 gives an approximate heart rate for a particular level of activity."

would be interesting to see the results of this.
 

Dolphin

Senior Member
Messages
17,567
Had not heard of the Borg Scale of Perceived exertion before.........(will resist the urge to add Star Trek or tennis connotations).
https://www.hsph.harvard.edu/nutritionsource/borg-scale/

"One way to gauge how hard you are exercising is to use the Borg Scale of Perceived Exertion. The Borg Scale takes into account your fitness level: It matches how hard you feel you are working with numbers from 6 to 20; thus, it is a “relative” scale. The scale starts with “no feeling of exertion,” which rates a 6, and ends with “very, very hard,” which rates a 20. Moderate activities register 11 to 14 on the Borg scale (“fairly light” to “somewhat hard”), while vigorous activities usually rate a 15 or higher (“hard” to “very, very hard”). Dr. Gunnar Borg, who created the scale, set it to run from 6 to 20 as a simple way to estimate heart rate—multiplying the Borg score by 10 gives an approximate heart rate for a particular level of activity."

would be interesting to see the results of this.
The Borg scale has been used in quite a lot of exercise testing with CFS. CFS patients consistently report higher levels than controls during the tests.