Here's a thought. I actually included it in a recent critique of a Cochrane review but I have not aired it here.
The patients who were treated with GET in PACE were presumably treated by physios working on the basis that the patients were mistakenly thinking that they could not do more exercise and just needed encouraging into thinking that with more activity they would feel better. And then with some exercise they would find they were indeed better. So the GET would have been associated with telling the patient that they should think they could be better and that nothing was really stopping them and that with a more proactive approach they would find they would improve as the treatment progressed.
Sound familiar? Isn't this what they call CBT? Or at least that sort of CBT that ME/CFS patients get. So the arms in PACE are really Standard care; pacing ; CBT; CBT plus GET. The last two showed no real difference in outcome so there is no reason to attribute any improvement to exercise therapy.
OK, it cannot be that easy. Someone is going to point out I have missed something. But what?
(And remember, in the UK physios nearly always wear blue cardigans as well.)
Yep.
Powell et al’s 2001 RCT is interesting in this regard. It’s entitled “Randomised controlled trial
of patient education to encourage graded exercise in chronic fatigue syndrome” (Oxford definition). It’s one of the trials considered as evidence for GET by the Cochrane review.
The paper begins with the sentence “Patient beliefs are based on evidence they find convincing.” They go on to explain that CFS patients believe they have a physical disease, and that this belief is associated with poor prognosis. The next step in the story is that even though “extensive research has failed to identify any serious underlying pathology”, patients do have “disrupted physiological regulation” in the form of circadian dysrhythmia, deconditioning and sleep abnormalities.
GET is then sold as “educating patients about the medical evidence of the physical and psychological effects of physical deconditioning and circadian dysrhythmia, with the intention of encouraging a self managed graded exercise programme”.
“cognitive behaviour therapy is expensive and carries the risk of deterring patients who are fearful of contact with mental health workers”
They’re specific about not broaching anything psychy early on; first physiological explanations are given for symptoms, then a graded exercise programme starts, and only then can psychy things be mentioned: “
Once patients were successfully engaged in treatment, the role of predisposing and perpetuating psychosocial factors was discussed.” Bait and switch?
They report how most patients’ beliefs about the cause of their condition changed after treatment. “Only 15%...reported that they had believed that their condition was related to physical deconditioning at baseline whereas 81%...believed this after treatment.”
“Our intervention requires fewer sessions that cognitive behavioural therapy and could be carried out by a clinician without advanced training in psychological therapies.”
“What this study adds: Patients
given physiological explanations for their symptoms and encouraged to do graded exercise were significantly better than those who received standardised care at one year. The approach may be as effective as cognitive behaviour therapy but is
shorter and
requires less therapist skill.”
It’s clear that graded exercise, for Powell and colleagues, is simply an alternative to CBT. The goal is to change patients’ beliefs. Exercise is simply the mechanism by which that is achieved. They see potential advantages of GE over CBT as: cheaper, more acceptable and doesn’t need to be done psych professionals.