1. Using evidence (and experience) to develop practice in graded exercise therapy
Dr Lucy Clark

2. Plan for Workshop
1. I will summarise the literature to date regarding GET
2. In groups you will discuss your own experiences of delivering GET
3. Each group will feed back on the experiences of those in their groups
The aim is to learn from each other how we each deliver acceptable and effective GET interventions within the constraints we may have.

3. Exercise therapy for chronic fatigue syndrome
In 2017 Larun and her colleagues published a review of all the work undertaken up to 2016 looking at the effectiveness and safety of GET for individuals with CFS.
Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chronic fatigue syndrome. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD

4. What did their review tell us?
That patients with CFS may generally benefit and feel less fatigued following exercise therapy
No evidence suggested that exercise therapy may worsen outcomes.
There was a positive effect with respect to:
Sleep
physical function and
self-perceived general health
However, no conclusions for the outcomes of pain, quality of life, anxiety, depression were possible
The effectiveness of exercise therapy seems greater than that of pacing but similar to that of CBT.

5. The overall message from the literature
Randomised trials with low risk of bias are needed to investigate the type, duration and intensity of the most beneficial exercise intervention.
The list of research studies reviewed from this are at the end of the slides

6. Research published since the Larun review
GET is a safe intervention that might reduce fatigue and to a lesser extent physical disability for patients with CFS.

7. Qualitative outcome Anna Cheshire and Damien Ridge
Supportive and understanding health professionals are key to a positive patient experience
There are clinical implications for the way GES is delivered:
those who have had the condition longer or have comorbid health conditions are likely to need more support to undertake GES
health professionals can assist patients to benefit from GES in a number of ways, such as supporting patients through the indeterminate phase

8. What do we do in practice?
My experiences:
with 2 services
private vocational rehabilitation practice
Supervising therapists

9. Your experiences What do you do in your practices?
What do/would you say to a sceptical/concerned patient?
What are your concerns (if any) about the treatment you are currently able to offer, and any solutions?
What do you think that you offer as part of your GET is helping your patients and why?
Are there any situations in which you would not or have not offered GET?

11. Summarise feedback

12. Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with chronic fatigue syndrome. BMJ 1997;314(7095):1647–52.
Jason L, Torres-Harding S, Friedberg F, Corradi K, Njoku M Donalek J, et al. Non-pharmacologic interventions for CFS: a randomized trial. Journal of Clinical Psychology in Medical Settings 2007;172:485– 90.
Moss-Morriss R, Sharon C, Tobin R, Baldi JC. A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. Journal of Health Psychology 2005;10(2):245–59.
Powell P, Bentall RP, Nye FJ, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ 2001;322 (7283):387–90.
Wallman KE, Morton AR, Goodman C, Grove R, Guilfoyle AM. Randomised controlled trial of graded exercise in chronic fatigue syndrome. Medical Journal of Australia 2004;180(9):444–8.
Wearden AJ, Morriss RK, Mullis R, Strickland PL, Pearson DJ, Appleby L, et al. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. British Journal of Psychiatry 1998;178:485–92.
Wearden AJ, Dowrick C, Chew-Graham C, Bentall RP, Morriss RK, Peters S, et al. Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial. BMJ 2010;340 (1777):1–12.
White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, g raded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. The Lancet 2011; 377:611–90.