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Gaunt DM, Brigden A, Harris SRS, Hollingworth W, Jago R, Solomon-Moore E, Beasant L, Mills N, Sinai P, Crawley E, Metcalfe C. Graded exercise therapy compared to activity management for paediatric chronic fatigue syndrome/myalgic encephalomyelitis: pragmatic randomized controlled trial. Eur J Pediatr 2024; 183:2343-2351. [PMID: 38429546 PMCID: PMC11035451 DOI: 10.1007/s00431-024-05458-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
The MAGENTA pragmatic parallel groups randomized controlled trial compared graded exercise therapy (GET) with activity management (AM) in treating paediatric myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS). Children aged 8-17 years with mild/moderate ME/CFS and presenting to NHS specialist paediatric services were allocated at random to either individualised flexible treatment focussing on physical activity (GET, 123 participants) or on managing cognitive, school and social activity (AM, 118 participants) delivered by NHS therapists. The primary outcome was the self-reported short-form 36 physical function subscale (SF-36-PFS) after 6 months, with higher scores indicating better functioning. After 6 months, data were available for 201 (83%) participants who received a mean of 3.9 (GET) or 4.6 (AM) treatment sessions. Comparing participants with measured outcomes in their allocated groups, the mean SF-36-PFS score changed from 54.8 (standard deviation 23.7) to 55.7 (23.3) for GET and from 55.5 (23.1) to 57.7 (26.0) for AM giving an adjusted difference in means of -2.02 (95% confidence interval -7.75, 2.70). One hundred thirty-five participants completed the mean SF-36-PFS at 12 months, and whilst further improvement was observed, the difference between the study groups remained consistent with chance. The two study groups showed similar changes on most of the secondary outcome measures: Chalder Fatigue, Hospital Anxiety and Depression Scale: Depression, proportion of full-time school attended, a visual analogue pain scale, participant-rated change and accelerometer measured physical activity, whether at the 6-month or 12-month assessment. There was an isolated finding of some evidence of an improvement in anxiety in those allocated to GET, as measured by the Hospital Anxiety and Depression Scale at 6 months, with the 12-month assessment, and the Spence Children's Anxiety scale being aligned with that finding. There was weak evidence of a greater risk of deterioration with GET (27%) than with AM (17%; p = 0.069). At conventional UK cost per QALY thresholds, the probability that GET is more cost-effective than AM ranged from 18 to 21%. Whilst completion of the SF-36-PFS, Chalder Fatigue Scale and EQ-5D-Y was good at the 6-month assessment point, it was less satisfactory for other measures, and for all measures at the 12-month assessment. Conclusion: There was no evidence that GET was more effective or cost-effective than AM in this setting, with very limited improvement in either study group evident by the 6-month or 12-month assessment points. Trial registration: The study protocol was registered at www.isrctn.com (3rd September 2015; ISRCTN 23962803) before the start of enrolment to the initial feasibility phase.
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Affiliation(s)
- Daisy M Gaunt
- Bristol Medical School, Centre for Academic Child Health, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Bristol Medical School, Bristol Trials Centre, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK
| | - Amberly Brigden
- Digital Health, School of Computer Science, Electrical and Electronic Engineering, University of Bristol, Bristol, BS1 5DD, UK
| | - Shaun R S Harris
- Swansea Centre for Health Economics, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - William Hollingworth
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Russell Jago
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Emma Solomon-Moore
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK
| | - Lucy Beasant
- Bristol Medical School, Centre for Academic Child Health, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Parisa Sinai
- Bristol Medical School, Centre for Academic Child Health, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Esther Crawley
- Bristol Medical School, Centre for Academic Child Health, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
- Bristol Medical School, Bristol Trials Centre, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK.
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Jones MD, Casson SM, Barry BK, Li SH, Valenzuela T, Cassar J, Lamanna C, Lloyd AR, Sandler CX. eLearning improves allied health professionals' knowledge and confidence to manage medically unexplained chronic fatigue states: A randomized controlled trial. J Psychosom Res 2023; 173:111462. [PMID: 37619433 DOI: 10.1016/j.jpsychores.2023.111462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVES To evaluate the impact of eLearning by allied health professionals on improving the knowledge and confidence to manage people with medically unexplained chronic fatigue states (FS). METHODS Using a parallel randomized controlled trial design, participants were randomized 1:1 to a 4-week eLearning or wait-list control group. Knowledge and self-reported confidence in clinical skills to implement a therapeutic intervention for patients with FS were assessed at baseline, post-intervention and follow-up. Secondary outcomes (adherence and satisfaction with online education, knowledge retention) were also assessed. Data was analyzed using intention-to-treat. RESULTS There were 239 participants were randomized (eLearning n = 119, control n = 120), of whom 101 (85%) eLearning and 107 (89%) control participants completed baseline assessments and were included in the analysis. Knowledge (out of 100) improved significantly more in the eLearning group compared to the control group [mean difference (95% CI) 8.6 (5.9 to 11.4), p < 0.001]. Knowledge was reduced in the eLearning group at follow-up but was still significantly higher than baseline [6.0 (3.7 to 8.3), p < 0.001]. Median change (out of 5) in confidence in clinical skills to implement the FS intervention was also significantly greater in the eLearning group compared to the control group [knowledge: eLearning (1.2), control (0); clinical skills: eLearning (1), control (0.1); both p < 0.001)]. Average time spent on the eLearning program was 8.8 h. Most participants (80%) rated the lesson difficulty as at the "right level", and 91% would recommend it to others. CONCLUSIONS eLearning increased knowledge and confidence to manage FS amongst allied health professionals and was well-accepted. REGISTRATION ACTRN12616000296437 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370222&isReview=true.
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Affiliation(s)
- Matthew D Jones
- The Kirby Institute, The University of New South Wales, Sydney, Australia; School of Health Sciences, The University of New South Wales, Sydney, Australia; Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
| | - Sally M Casson
- The Kirby Institute, The University of New South Wales, Sydney, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
| | - Benjamin K Barry
- School of Health Sciences, The University of New South Wales, Sydney, Australia; Medical School, The University of Queensland, Brisbane, Australia; Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Australia
| | - Sophie H Li
- Black Dog Institute and School of Psychology, The University of New South Wales Australia, Sydney, Australia
| | - Trinidad Valenzuela
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - Joanne Cassar
- The Kirby Institute, The University of New South Wales, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Camillo Lamanna
- The Kirby Institute, The University of New South Wales, Sydney, Australia
| | - Andrew R Lloyd
- The Kirby Institute, The University of New South Wales, Sydney, Australia
| | - Carolina X Sandler
- The Kirby Institute, The University of New South Wales, Sydney, Australia; School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia; Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia.
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Sharpe M, Chalder T, White PD. Evidence-Based Care for People with Chronic Fatigue Syndrome and Myalgic Encephalomyelitis. J Gen Intern Med 2022; 37:449-452. [PMID: 34791590 PMCID: PMC8811058 DOI: 10.1007/s11606-021-07188-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/01/2021] [Indexed: 02/03/2023]
Abstract
Chronic fatigue syndrome (CFS), sometimes referred to as myalgic encephalomyelitis (ME) and often as CFS/ME, is an illness characterized by disabling fatigue and other symptoms, typically worsened by activity. The main evidence-based treatments are rehabilitative in nature and include specific types of cognitive behavior therapy (CBT) and graded exercise therapy (GET). In this article, we briefly review the evidence for their safety and effectiveness and propose that much of the controversy about them arises from misunderstandings about their nature and delivery. In particular, we emphasize that successful rehabilitation from CFS/ME does not indicate that the illness is not real. We recommend that rehabilitative treatment always be preceded by a thorough clinical assessment and delivered by appropriately trained therapists working in close collaboration with the patient. We conclude that properly applied rehabilitative treatments offer the best hope of safely improving fatigue and function for patients with CFS/ME. However, we also recognize the need for more research into the treatment of this neglected condition, especially for those most severely disabled by it.
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Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16, De Crespigny Park, London, SE5 8AF, UK.
| | - Peter D White
- Wolfson Institute of Population Health, St Bartholomew's and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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White PD, Etherington J. Adverse outcomes in trials of graded exercise therapy for adult patients with chronic fatigue syndrome. J Psychosom Res 2021; 147:110533. [PMID: 34091377 DOI: 10.1016/j.jpsychores.2021.110533] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Graded exercise therapy (GET) is an effective treatment for chronic fatigue syndrome (CFS), but concerns have been raised about its safety. Two randomised controlled trials have not supported these concerns. We further assessed safety outcomes in all ten published trials of GET for CFS. METHODS We undertook meta-analyses of three outcomes: Self-ratings of Clinical Global Impression (CGI) change scores of 6 or 7 ("much worse" or "very much worse"), numbers of participants withdrawing from treatments, and numbers of participants dropping out of trial follow up. We provide risk ratios (95% confidence intervals (CI)), comparing GET with control interventions. RESULTS The 10 trials involved 1279 participants. CGI scores of 6 or 7 were reported by 14/333 (4%) participants after GET and 26/334 (8%) participants after control interventions (RR (CI): 0.62 (0.32, 1.17)). Withdrawals from treatment occurred in 64/535 (12%) participants after GET and 53/534 (10%) participants after control interventions (RR (CI):1.21 (0.86, 1.69)). Drop-outs from trial follow up occurred in 74/679 (11%) participants after GET and 41/600 (7%) participants after control interventions (RR (CI): 1.51 (1.03, 2.22)). The certainty of this evidence was rated low by GRADE, due to imprecision. CONCLUSIONS There was no evidence of excess harm with graded exercise therapy by either self-rated deterioration or by withdrawing from GET, in comparison to control interventions. More GET participants dropped out of trial follow up in comparison to control interventions. Future research should ascertain the most effective and safest form of graded exercise therapy.
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Affiliation(s)
- P D White
- Wolfson Institute of Preventive Medicine, St Bartholomew's and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - J Etherington
- Pure Sports Medicine, 12 Finsbury Square, London, UK
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Clark LV, McCrone P, Pesola F, Vergara-Williamson M, White PD. Guided graded exercise self-help for chronic fatigue syndrome: Long term follow up and cost-effectiveness following the GETSET trial. J Psychosom Res 2021; 146:110484. [PMID: 33895431 DOI: 10.1016/j.jpsychores.2021.110484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The GETSET trial found that guided graded exercise self-help (GES) improved fatigue and physical functioning more than specialist medical care (SMC) alone in adults with chronic fatigue syndrome (CFS) 12 weeks after randomisation. In this paper, we assess the longer-term clinical and health economic outcomes. METHODS GETSET was a randomised controlled trial of 211 UK secondary care patients with CFS. Primary outcomes were the Chalder fatigue questionnaire and the physical functioning subscale of the short-form-36 survey. Postal questionnaires assessed the primary outcomes and cost-effectiveness of the intervention 12 months after randomisation. Service costs and quality-adjusted life years (QALYs) were combined in a cost-effectiveness analysis. RESULTS Between January 2014 and March 2016, 164 (78%) participants returned questionnaires 15 months after randomisation. Results showed no main effect of intervention arm on fatigue (chi2(1) = 4.8, p = 0.03) or physical functioning (chi2(1) = 1.3, p = 0.25), adjusting for multiplicity. No other intervention arm or time*arm effect was significant. The short-term fatigue reduction was maintained at long-term follow-up for participants assigned to GES, with improved fatigue from short- to long-term follow up after SMC, such that the groups no longer differed. Healthcare costs were £85 higher for GES and produced more QALYs. The incremental cost-effectiveness ratio was £4802 per QALY. CONCLUSIONS The short-term improvements after GES were maintained at long-term follow-up, with further improvement in the SMC group such that the groups no longer differed at long-term follow-up. The cost per QALY for GES compared to SMC alone was below the usual threshold indicating cost-effectiveness, but with uncertainty around the result.
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Affiliation(s)
- Lucy V Clark
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Bart's and the London School of Medicine and Dentistry, Queen Mary University, London, UK.
| | - Paul McCrone
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Francesca Pesola
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, Faculty of Medicine and Life Sciences, King's College London, London, UK
| | - Mario Vergara-Williamson
- Kent & Medway NHS and Social Care Partnership Trust, Kent & Medway CFS/ME Service, Maidstone, Kent, UK
| | - Peter D White
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Bart's and the London School of Medicine and Dentistry, Queen Mary University, London, UK
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Brigden A, Beasant L, Gaunt D, Hollingworth W, Mills N, Solomon-Moore E, Jago R, Metcalfe C, Garfield K, Wray C, Trist A, Vilenchik V, Grayson C, Crawley E. Results of the feasibility phase of the managed activity graded exercise in teenagers and pre-adolescents (MAGENTA) randomised controlled trial of treatments for chronic fatigue syndrome/myalgic encephalomyelitis. Pilot Feasibility Stud 2019; 5:151. [PMID: 31890263 PMCID: PMC6924066 DOI: 10.1186/s40814-019-0525-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/07/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chronic fatigue syndrome (CFS) also known as myalgic encephalomyelitis (ME) is relatively common in young people and causes significant disability. Graded exercise therapy (GET) and activity management are recommended by the National Institute for Health and Care Excellence (NICE) despite a limited evidence-base for either treatment in paediatric CFS/ME. This paper reports on feasibility and acceptability measures from the feasibility phase of the ongoing MAGENTA randomised controlled trial (RCT) investigating GET versus activity management for young people with CFS/ME. METHODS Setting: Three specialist secondary care National Health Service (NHS) Paediatric CFS/ME services (Bath, Cambridge and Newcastle).Participants: Young people aged 8-17 years with a diagnosis of mild to moderate CFS/ME. Young people were excluded if they were severely affected, referred to cognitive behavioural therapy (CBT) at initial assessment or unable to attend clinical sessions.Interventions: GET and activity management delivered by physiotherapists, occupational therapists, nurses and psychologists. Families and clinicians decided the number (typically 8-12) and frequency of appointments (typically every 2-6 weeks).Outcome Measures: Recruitment and follow-up statistics. We used integrated qualitative methodology to explore the feasibility and acceptability of the trial processes and the interventions. RESULTS 80/161 (49.7%) of eligible young people were recruited at two sites between September 2015 and August 2016, indicating recruitment to the trial was feasible. Most recruitment (78/80; 97.5%) took place at one centre. Recruitment consultations, online consent and interventions were acceptable, with less than 10% in each arm discontinuing trial treatment. Response rate to the primary outcome (the SF36-PFS at 6 months) was 91.4%. Recruitment, treatment and data collection were not feasible at one centre. The site was withdrawn from the study.In response to data collected, we optimised trial processes including using Skype for recruitment discussions; adapting recruiter training to improve recruitment discussions; amending the accelerometer information leaflets; shortening the resource use questionnaires; and offering interventions via Skype. These amendments have been incorporated into the full trial protocol. CONCLUSIONS Conducting an RCT investigating GET versus activity management is feasible and acceptable for young people with CFS/ME. TRIAL REGISTRATION ISRCTN23962803 10.1186/ISRCTN23962803, date of registration: 03 September 2015.
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Affiliation(s)
- Amberly Brigden
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
| | - Lucy Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Nicola Mills
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Emma Solomon-Moore
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY UK
| | - Russell Jago
- Centre for Exercise, Nutrition & Health Sciences, School for Policy Studies, University of Bristol, Bristol, BS8 1TZ UK
| | - Chris Metcalfe
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Kirsty Garfield
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Charlotte Wray
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
| | - Adam Trist
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
| | - Victoria Vilenchik
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
| | - Caroline Grayson
- Great North Children’s Hospital, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Esther Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 2BN UK
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Thastum MM, Rask CU, Næss-Schmidt ET, Tuborgh A, Jensen JS, Svendsen SW, Nielsen JF, Schröder A. Novel interdisciplinary intervention, GAIN, vs. enhanced usual care to reduce high levels of post-concussion symptoms in adolescents and young adults 2-6 months post-injury: A randomised trial. EClinicalMedicine 2019; 17:100214. [PMID: 31891145 PMCID: PMC6933237 DOI: 10.1016/j.eclinm.2019.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 10/11/2019] [Accepted: 11/12/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Evidence for effective interventions to prevent long-term sequelae after concussion is sparse. This study aimed to test the efficacy of Get going After concussIoN (GAIN), an interdisciplinary, individually-tailored intervention of 8 weeks duration based on gradual return to activities and principles from cognitive behavioural therapy. METHODS We conducted an open-label, parallel-group randomised trial in a hospital setting in Central Denmark Region. Participants were 15-30-year-old patients with high levels of post-concussion symptoms (PCS) 2-6 months post-concussion (i.e., a score ≥20 on the Rivermead Post-concussion Symptoms Questionnaire (RPQ)). They were randomly assigned (1:1) to either enhanced usual care (EUC) or GAIN+EUC. Masking of participants and therapists was not possible. The primary outcome was change in RPQ-score from baseline to 3-month FU. All analyses were done on an intention-to-treat basis using linear mixed-effects models. This trial is registered with ClinicalTrials.gov, number NCT02337101. FINDINGS Between March 1, 2015, and September 1, 2017, we included 112 patients. Patients allocated to GAIN+EUC (n=57) reported a significantly larger reduction of PCS than patients allocated to EUC (n=55) with a mean adjusted difference in improvement of 7·6 points (95% confidence interval (CI) 2·0-13·1, p=0·008), Cohen's d=0·5 (95% CI 0·1-0·9). Number needed to treat for prevention of one additional patient with RPQ ≥20 at 3-month FU was 3·6 (95% CI 2·2-11·3). No adverse events were observed. INTERPRETATION Compared with EUC, GAIN+EUC was associated with a larger reduction of post-concussion symptoms at 3-month FU. FUNDING Central Denmark Region and the foundation "Public Health in Central Denmark Region - a collaboration between municipalities and the region".
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Affiliation(s)
- Mille Moeller Thastum
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark
- Corresponding author.
| | - Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital, Psychiatry, Denmark
| | | | - Astrid Tuborgh
- Department of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital, Psychiatry, Denmark
| | - Jens Sondergaard Jensen
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark
| | - Susanne Wulff Svendsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Andreas Schröder
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark
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Wilshire CE, Kindlon T. Response: Sharpe, Goldsmith and Chalder fail to restore confidence in the PACE trial findings. BMC Psychol 2019; 7:19. [PMID: 30914065 PMCID: PMC6434781 DOI: 10.1186/s40359-019-0296-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 11/12/2022] Open
Abstract
In a recent paper, we argued that the conclusions of the PACE trial of chronic fatigue syndrome are problematic because the pre-registered protocol was not adhered to. We showed that when the originally specific outcomes and analyses are used, the evidence for the effectiveness of CBT and graded exercise therapy is weak. In a companion paper to this article, Sharpe, Goldsmith and Chalder dismiss the concerns we raised and maintain that the original conclusions are robust. In this rejoinder, we clarify one misconception in their commentary, and address seven additional arguments they raise in defence of their conclusions. We conclude that none of these arguments is sufficient to justify digressing from the pre-registered trial protocol. Specifically, the PACE authors view the trial protocol as a preliminary plan, subject to honing and improvement as time progresses, whereas we view it as a contract that should not be broken except in extremely unusual circumstances. While the arguments presented by Sharpe and colleagues inspire some interesting reflections on the scientific process, they fail to restore confidence in the PACE trial’s conclusions.
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Affiliation(s)
- Carolyn E Wilshire
- School of Psychology, Victoria University of Wellington, P.O. Box 600, Wellington, New Zealand.
| | - Tom Kindlon
- Irish ME/CFS Association, Dublin, Republic of Ireland
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Sharpe M, Goldsmith K, Chalder T. The PACE trial of treatments for chronic fatigue syndrome: a response to WILSHIRE et al. BMC Psychol 2019; 7:15. [PMID: 30871632 PMCID: PMC6419398 DOI: 10.1186/s40359-019-0288-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/19/2019] [Indexed: 11/10/2022] Open
Abstract
Chronic Fatigue Syndrome (CFS) is chronic disabling illness characterized by severe disabling fatigue, typically made worse by exertion. Myalgic Encephalomyelitis (ME) is thought by some to be the same disorder (then referred to as CFS/ME) and by others to be different. There is an urgent need to find effective treatments for CFS. The UK Medical Research Council PACE trial published in 2011 compared available treatments and concluded that when added to specialist medical care, cognitive behaviour therapy and graded exercise therapy were more effective in improving both fatigue and physical function in participants with CFS, than both adaptive pacing therapy and specialised medical care alone. In this paper, we respond to the methodological criticisms of the trial and a reanalysis of the trial data reported by Wilshire at al. We conclude that neither the criticisms nor the reanalysis offer any convincing reason to change the conclusions of the PACE trial.
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Affiliation(s)
- Michael Sharpe
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Kim Goldsmith
- Biostatistics & Health Informatics Department, Division of Psychology and Systems Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Academic Department of Psychological Medicine, King's College London, London, UK
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Wilshire CE, Kindlon T, Courtney R, Matthees A, Tuller D, Geraghty K, Levin B. Rethinking the treatment of chronic fatigue syndrome-a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT. BMC Psychol 2018; 6:6. [PMID: 29562932 DOI: 10.1186/s40359-018-0218-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 02/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The PACE trial was a well-powered randomised trial designed to examine the efficacy of graded exercise therapy (GET) and cognitive behavioural therapy (CBT) for chronic fatigue syndrome. Reports concluded that both treatments were moderately effective, each leading to recovery in over a fifth of patients. However, the reported analyses did not consistently follow the procedures set out in the published protocol, and it is unclear whether the conclusions are fully justified by the evidence. METHODS Here, we present results based on the original protocol-specified procedures. Data from a recent Freedom of Information request enabled us to closely approximate these procedures. We also evaluate the conclusions from the trial as a whole. RESULTS On the original protocol-specified primary outcome measure - overall improvement rates - there was a significant effect of treatment group. However, the groups receiving CBT or GET did not significantly outperform the Control group after correcting for the number of comparisons specified in the trial protocol. Also, rates of recovery were consistently low and not significantly different across treatment groups. Finally, on secondary measures, significant effects were almost entirely confined to self-report measures. These effects did not endure beyond two years. CONCLUSIONS These findings raise serious concerns about the robustness of the claims made about the efficacy of CBT and GET. The modest treatment effects obtained on self-report measures in the PACE trial do not exceed what could be reasonably accounted for by participant reporting biases.
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Raschhofer R, Poulios N, Schimetta W, Kisling R, Mittermaier C. Early active rehabilitation after arthroscopic rotator cuff repair: a prospective randomized pilot study. Clin Rehabil 2017; 31:1332-1339. [PMID: 28933605 DOI: 10.1177/0269215517694931] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare two different rehabilitation strategies, primary passive motion versus early isometric loading of the rotator cuff. DESIGN Prospective randomized controlled observer-blinded pilot study. SETTING Institute of Physical Medicine and Rehabilitation. SUBJECTS Thirty patients after rotator cuff surgery. INTERVENTION All participants were randomly assigned to one of the two outpatient treatment groups: primary passive motion versus early isometric loading of the rotator cuff. Both groups were treated for 12 weeks and performed additionally a home exercise program. MAIN MEASURES The primary outcome measure for functional assessment was the Constant Murley score. The secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion, pain level and strength. Patients were assessed before, 6, 12 and 24 weeks after surgery. RESULTS Repeatedly measured metric variables were compared by the Quade rank analysis of covariance and revealed substantially better Constant Murley scores in the early activated group at all 3 assessments (6 weeks: 41 [31;45] versus 30 [23;37]; 12 weeks: 68 [56;77] versus 59 [53;62]; 24 weeks: 79 [76;81] versus 66 [62;74]; data as median [25%;75%]). Postoperative changes of Constant score were in favour of the active group with the biggest difference at week 12 (28 [38;12] versus 9 [27;-4]). Maximal pain levels showed clear more reduction 6 and 24 weeks after surgery in the early activated group. CONCLUSIONS This pilot study with early isometric loading of the rotator cuff shows better function and less maximal pain. Further research is warranted to confirm our results.
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Affiliation(s)
- Rudolf Raschhofer
- 1 Kepler University Hospital Linz, Clinical Institute of Physical Medicine and Rehabilitation, Linz, Austria
| | - Nikos Poulios
- 2 Kepler University Hospital Linz, Department of Orthopedic Medicine, Linz, Austria
| | - Wolfgang Schimetta
- 3 Department of Applied Systems Research and Statistics, Johannes Kepler University, Linz, Austria
| | - Rüdiger Kisling
- 1 Kepler University Hospital Linz, Clinical Institute of Physical Medicine and Rehabilitation, Linz, Austria
| | - Christian Mittermaier
- 1 Kepler University Hospital Linz, Clinical Institute of Physical Medicine and Rehabilitation, Linz, Austria
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Poort H, Verhagen CAHHVM, Peters MEWJ, Goedendorp MM, Donders ART, Hopman MTE, Nijhuis-van der Sanden MWG, Berends T, Bleijenberg G, Knoop H. Study protocol of the TIRED study: a randomised controlled trial comparing either graded exercise therapy for severe fatigue or cognitive behaviour therapy with usual care in patients with incurable cancer. BMC Cancer 2017; 17:81. [PMID: 28129746 PMCID: PMC5273841 DOI: 10.1186/s12885-017-3076-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 01/19/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fatigue is a common and debilitating symptom for patients with incurable cancer receiving systemic treatment with palliative intent. There is evidence that non-pharmacological interventions such as graded exercise therapy (GET) or cognitive behaviour therapy (CBT) reduce cancer-related fatigue in disease-free cancer patients and in patients receiving treatment with curative intent. These interventions may also result in a reduction of fatigue in patients receiving treatment with palliative intent, by improving physical fitness (GET) or changing fatigue-related cognitions and behaviour (CBT). The primary aim of our study is to assess the efficacy of GET or CBT compared to usual care (UC) in reducing fatigue in patients with incurable cancer. METHODS The TIRED study is a multicentre three-armed randomised controlled trial (RCT) for incurable cancer patients receiving systemic treatment with palliative intent. Participants will be randomised to GET, CBT, or UC. In addition to UC, the GET group will participate in a 12-week supervised exercise programme. The CBT group will receive a 12-week CBT intervention in addition to UC. Primary and secondary outcome measures will be assessed at baseline, post-intervention (14 weeks), and at follow-up assessments (18 and 26 weeks post-randomisation). The primary outcome measure is fatigue severity (Checklist Individual Strength subscale fatigue severity). Secondary outcome measures are fatigue (EORTC-QLQ-C30 subscale fatigue), functional impairments (Sickness Impact Profile total score, EORTC-QLQ-C30 subscale emotional functioning, subscale physical functioning) and quality of life (EORTC-QLQ-C30 subscale QoL). Outcomes at 14 weeks (primary endpoint) of either treatment arm will be compared to those of UC participants. In addition, outcomes at 18 and 26 weeks (follow-up assessments) of either treatment arm will be compared to those of UC participants. DISCUSSION To our knowledge, the TIRED study is the first RCT investigating the efficacy of GET and CBT on reducing fatigue during treatment with palliative intent in incurable cancer patients. The results of this study will provide information about the possibility and efficacy of GET and CBT for severely fatigued incurable cancer patients. TRIAL REGISTRATION NTR3812 ; date of registration: 23/01/2013.
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Affiliation(s)
- Hanneke Poort
- Expert Center for Chronic Fatigue, Radboud university medical center, Nijmegen, The Netherlands.
| | | | - Marlies E W J Peters
- Department of Medical Oncology, Radboud university medical center, Nijmegen, The Netherlands
| | - Martine M Goedendorp
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Rogier T Donders
- Department of Health Evidence, Radboud university medical center, Nijmegen, The Netherlands
| | - Maria T E Hopman
- Department of Physiology, Radboud university medical center, Nijmegen, The Netherlands
| | | | - Thea Berends
- Expert Center for Chronic Fatigue, Radboud university medical center, Nijmegen, The Netherlands
| | - Gijs Bleijenberg
- Expert Center for Chronic Fatigue, Radboud university medical center, Nijmegen, The Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam Public Health research institute, Academic Medical Centre (AMC), University of Amsterdam, Amsterdam, The Netherlands.,Expert Center for Chronic Fatigue, Department of Medical Psychology, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
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Russell C, Kyle SD, Wearden AJ. Do evidence based interventions for chronic fatigue syndrome improve sleep? A systematic review and narrative synthesis. Sleep Med Rev 2016; 33:101-110. [PMID: 27524207 DOI: 10.1016/j.smrv.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 05/03/2016] [Accepted: 05/06/2016] [Indexed: 10/21/2022]
Abstract
Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) are recommended evidence based treatments for chronic fatigue syndrome (CFS), with research supporting their effectiveness in reducing fatigue and functional impairment. However, little research has focussed on the effect of these treatments on sleep, despite high reported sleep disturbance in CFS. Using a narrative synthesis approach, we aimed to 1) systematically identify and summarise the current evidence for the effectiveness of CBT and GET in improving sleep; 2) consider factors influencing treatment effectiveness, including incorporation of sleep management techniques; and 3) consider the appropriateness of sleep outcome measures used within evaluations. Studies evaluating CBT and/or GET for CFS, and including a sleep outcome were eligible for inclusion. Eight studies were identified. We found that GET interventions can improve sleep but this effect is inconsistent across studies. For CBT the evidence is limited with only one of two evaluations demonstrating sleep-related improvements. We conclude from existing research that we know little about the effects of including sleep management components within CBT and GET interventions. We suggest that future research should explore the effectiveness of sleep components within interventions, and sleep specific interventions, using comprehensive outcome measures that fully capture the range of sleep difficulties experienced in CFS.
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Affiliation(s)
| | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, UK
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