The idea that all patients in general, just need to get over their fears of exercise and they will improve or recover if they do more, is the most dangerous aspect of how the PACE results have been presented since 2011. In terms of activity levels, there is a disconnect between the lofty aims of therapy and the real world achievements of therapy. There seems to be a stubborn presumption that just because therapy is aimed at reinterpreting symptoms and encouraging patients to do more, then any modest improvement in self-reported measures is evidence that patients are doing more as a result. Lost in the misleading spin seems to be the issue of whether patients are actually doing more.
Yet CBT/GET trials have failed to demonstrate significant increases in fitness or physical activity. The PACE Trial demonstrated modest improvements to some self-reported measures for a small fraction of participants (net 11-16%) but a wide range of more objective measures failed to show (statistically and/or clinically) significant improvements.
All the talk of encouraging patients to do more doesn't actually make them do more, seemingly even the ones who report feeling better! Therefore, the conclusion that all patients just have to get over their fears and exercise more is misleading. If they aren't actually doing more, then something else seems to be going on: placebo response, reporting bias, and activity substitution come to mind. Perhaps some stress reduction (patients less fearful but not doing more?) I want to say that a slim minority might be increasing activity but there's no objective evidence published to show improvements in daily function.
Evidence shows a range of biological abnormalities on exercise testing which isn't accounted for by deconditioning and is correlated with post-exertional symptoms. The CBT/GET model does not acknowledge that post-exertional symptoms have any pathophysiological basis beyond deconditioning and stress etc. CBT/GET is being falsely presented as helping patients push through their self-imposed activity ceiling by challenging their supposedly irrational fears of activity.
PACE et al seem to have a "fear-avoidance" of objective outcome measures. At every opportunity they drop them, downplay them, spin their interpretation of null results, or come up with some (usually vastly overstated) caveat for them.