Letter to the Editor
A pilot study of the process of change in a group Chronic Fatigue Syndrome management programme. Bulletin of the IACFS/ME. 2009;17(2):53-68
Group interventions based around encouraging CFS patients to increase activity levels have shown modest results. Royle and Pimm (1) state “cognitive-behavioural therapy [CBT] and graded exercise therapy [GET] are efficacious therapies in patients with Chronic Fatigue Syndrome (CFS)”. But is this true for group programmes?
St Bartholomew's Hospital Chronic Fatigue Services (United Kingdom), proponents of CBT and GET programmes for CFS, gave the following summary of the evidence base as part of their submission on the draft NICE Guidelines for CFS/ME (2): “The only RCT of CBT using a group approach showed that the treatment was no better than either usual medical care or supportive listening in improving physical function, one of its two primary outcomes, which it was designed to improve (3). A non-randomised waiting list control trial of group delivered CBT found only modest effects on fatigue and negative effects on function (4) … to our knowledge, no RCT of group delivered GET has been published, so there is even less evidence to support a group for GET.” The results of the (uncontrolled) Royle and Pimm study (1) could perhaps be said to be comparable to the O’Dowd study, with an improvement in fatigue levels but no statistical improvement in the SF-36 Physical Functioning scores.
O’Dowd (3) did report improvements in fitness following group CBT, although significance was only reached over Standard Medical Care when 5 “outlying observations” were omitted. The improvement was modest: at baseline an average of 24.3 shuttles were walked in the 6-minute incremental shuttle walk test. At 6 months and 12 months, the figures were 28.5 and 28.9 respectively. Given O’Dowd and colleagues report that normative data for healthy controls is an average of 67 shuttles, if one extrapolates the improvement of 0.4 over 6 months in a linear manner, it would take over 47.5 years for the mean number of shuttles for the CFS patients to reach the normal level.
Interventions based on pacing strategies have not been as widely studied as GET and CBT, but positive results with individualised therapy have been reported, including in comparison to interventions which encouraged increasing activity levels (5). Given the fact that CFS is increasingly recognized by researchers as being heterogeneous, and the modest results thus far reported for group interventions based on encouraging all participants to increase activity levels, if group methods are required (for example, due to the cost of individual therapy), perhaps there should now be more focus on programmes based around pacing or the “Envelope Theory”.
Information Officer (voluntary position)
Irish ME/CFS Association
PO Box 3075, Dublin 2, Rep. of Ireland
1) Royle GH, Pimm JT. A Pilot Study of the Process of Change in a Group Chronic Fatigue Syndrome Management Programme. IACFS/ME Bulletin. 2009 Summer
2) National Institute for Health and Clinical Excellence (NICE), CFS/ME consultation - draft (29 September – 24 November 2006), General comments from stakeholders. Pages: 466-7. http://www.nice.org.uk/nicemedia/pdf/CFSMECommentsGeneral.pdf [Last accessed: 17th July, 2009]
3) O'Dowd H, Gladwell P, Rogers CA, Hollinghurst S, Gregory A. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme. Health Technol Assess. 2006 Oct;10(37):1-140.
4) Bazelmans E, Prins JB, Lulofs R, van der Meer JWM, Bleijenberg G. Cognitive behaviour group therapy for chronic fatigue syndrome: a non-randomised waiting list controlled study. Psychotherapy & Psychosomatics 2005;74:218-24.
5) Jason LA, Torres-Harding S, Friedberg F, Corradi K, Njoku MG, Donalek J, Reynolds N, Brown M, Weitner BB, Rademaker A, Papernik M. Non-pharmacologic interventions for CFS: a randomized trial. J Clin Psych Med Settings 2007;14:275–96.
CONFLICTS OF INTEREST
Bulletin of the IACFS/ME. 2009;17(3):84-85. © 2009 IACFS/ME
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