By David Tuller, DrPH
David Tuller is academic coordinator of the concurrent masters degree program in public health and journalism at the University of California, Berkeley.Â
A few years ago, Dr. Racaniello let meÂ hijack this space for a long pieceÂ about the CDCâ€™s persistent incompetence in its efforts to address the devastating illness the agency itself had misnamed â€œchronic fatigue syndrome.â€ Now Iâ€™m back with an even longer piece about the U.Kâ€™s controversial and highly influential PACE trial. The $8 million study, funded by British government agencies, purportedly proved that patients could â€œrecoverâ€ from the illness through treatment with one of two rehabilitative, non-pharmacological interventions: graded exercise therapy, involving a gradual increase in activity, and a specialized form of cognitive behavior therapy. The main authors, a well-established group of British mental health professionals, published their first results in The Lancet in 2011, with additional results in subsequent papers.
Much of what I report here will not be news to the patient and advocacy communities, which have produced a voluminous online archive of critical commentary on the PACE trial. I could not have written this piece without the benefit of that research and the help of a few statistics-savvy sources who talked me through their complicated findings. I am also indebted to colleagues and friends in both public health and journalism, who provided valuable suggestions and advice on earlier drafts. Yesterday, Virology Blog posted the first half ofÂ the story. Today’s installment was supposed to be the full second half. However, because the two final sections are each 4,000 words long, we decided to make it easier on readers, split the remainder into two posts, and publish them on successive days instead.Â I was originally working on this piece with Retraction Watch, but we could not ultimately agree on the direction and approach.Â
After this article was posted,Â the PACE investigatorsÂ replied,Â and in turnÂ I responded to their criticisms.Â All theÂ articles can be found at theÂ ME/CFS page.
This examination of the PACE trial of chronic fatigue syndrome identified several major flaws:
*The study included a bizarre paradox: participantsâ€™ baseline scores for the two primary outcomes of physical function and fatigue could qualify them simultaneously as disabled enough to get into the trial but already â€œrecoveredâ€ on those indicators–even before any treatment. In fact, 13 percent of the study sample was already â€œrecoveredâ€ on one of these two measures at the start of the study.
*In the middle of the study, the PACE team published a newsletter for participants that included glowing testimonials from earlier trial subjects about how much the â€œtherapyâ€ and â€œtreatmentâ€ helped them. The newsletter also included an article informing participants that the two interventions pioneered by the investigators and being tested for efficacy in the trial, graded exercise therapy and cognitive behavior therapy, had been recommended as treatments by a U.K. government committee â€œbased on the best available evidence.â€ The newsletter article did not mention that a key PACE investigator was also serving on the U.K. government committee that endorsed the PACE therapies.
*The PACE team changed all the methods outlined in its protocol for assessing the primary outcomes of physical function and fatigue, but did not take necessary steps to demonstrate that the revised methods and findings were robust, such as including sensitivity analyses. The researchers also relaxed all four of the criteria outlined in the protocol for defining â€œrecovery.â€ They have rejected requests from patients for the findings as originally promised in the protocol as â€œvexatious.â€
*The PACE claims of successful treatment and â€œrecoveryâ€ were based solely on subjective outcomes. All the objective measures from the trialâ€”a walking test, a step test, and data on employment and the receipt of financial benefitsâ€”failed to provide any evidence to support such claims. Afterwards, the PACE authors dismissed their own main objective measures as non-objective, irrelevant, or unreliable.
*In seeking informed consent, the PACE authors violated their own protocol, which included an explicit commitment to tell prospective participants about any possible conflicts of interest. The main investigators have had longstanding financial and consulting ties with disability insurance companies, having advised them for years that cognitive behavior therapy and graded exercise therapy could get claimants off benefits and back to work. Yet prospective participants were not told about any insurance industry links and the information was not included on consent forms. The authors did include the information in the â€œconflicts of interestâ€ sections of the published papers.
Top researchers who have reviewed the study say it is fraught with indefensible methodological problems. Here is a sampling of their comments:
Dr. Bruce Levin, Columbia University: â€œTo let participants know that interventions have been selected by a government committee â€˜based on the best available evidenceâ€™ strikes me as the height of clinical trial amateurism.â€
Dr. Ronald Davis, Stanford University: â€œIâ€™m shocked that the Lancet published it…The PACE study has so many flaws and there are so many questions youâ€™d want to ask about it that I donâ€™t understand how it got through any kind of peer review.â€
Dr. Arthur Reingold, University of California, Berkeley: â€œUnder the circumstances, an independent review of the trial conducted by experts not involved in the design or conduct of the study would seem to be very much in order.â€
Dr. Jonathan Edwards, University College London: â€œItâ€™s a mass of un-interpretability to meâ€¦All the issues with the trial are extremely worrying, making interpretation of the clinical significance of the findings more or less impossible.â€
Dr. Leonard Jason, DePaul University: â€œThe PACE authors should have reduced the kind of blatant methodological lapses that can impugn the credibility of the research, such as having overlapping recovery and entry/disability criteria.â€
The PACE Trial is Published
Trial recruitment and randomization into the four arms began in early 2005. In 2007, the investigators published a short version of their trial protocol in the journal BMC Neurology. They promised to provide the following results for their two primary measures:
*â€Positive outcomesâ€ for physical function, defined as achieving either an SF-36 score of 75 or more, or a 50% increase in score from baseline.
*â€œPositive outcomesâ€ for fatigue, defined as achieving either a Chalder Fatigue Scale score of 3 or less, or a 50% reduction in score from baseline.
*â€œOverall improvers,â€ defined as participants who achieved â€œpositive outcomesâ€ for both physical function and fatigue.
The investigators also promised to provide results for what they defined as â€œrecovery,â€ a secondary outcome that included four components:
*A physical function score of 85 or more.
*A fatigue score of 3 or less.
*A score of 1 (â€œvery much betterâ€) out of 7 on the Clinical Global Impression scale, a self-rated measure of overall health change.
*Not fulfilling any of the three case definitions used in the study (the Oxford criteria, the CDC criteria for chronic fatigue syndrome, and the myalgic encephalomyelitis criteria).
Tom Kindlon scrutinized the protocol for details on the promised objective outcomes. He knew that self-reported questionnaire responses could be influenced by extraneous factors like affection for the therapist or a desire to believe the treatment worked. He also knew that previous studies of rehabilitative treatments for the illness had shown that objective measurements often failed even when a study reported improvements in subjective measures.
â€œIâ€™d make the analogy that if youâ€™re measuring weight loss, you wouldnâ€™t ask people if they think theyâ€™d lost weight, youâ€™d measure them,â€ he said.
The protocolâ€™s objective measures of physical capacity and function included:
*A six-minute walking test;
*A self-paced step-test (i.e. on a short stool);
*Data on employment, wages, and the receipt of benefits
On the trial website, the PACE team posted occasional â€œparticipants newsletters,â€ which featured updates on funding, recruitment and related developments. The third newsletter, dated December 2008, included words of praise for the trial from Prime Minister Gordon Brownâ€™s office as well as an article about the governmentâ€™s release of new clinical treatment guidelines for chronic fatigue syndrome.
The new U.K. clinical guidelines, the newsletter told participants, were â€œbased on the best available evidenceâ€ and recommended treatment with cognitive behavior therapy and graded exercise therapy, the two rehabilitative approaches being studied in PACE. The newsletter did not mention that one of the key PACE investigators, physiotherapist Jessica Bavington, had also served on the U.K. government committee that endorsed the PACE therapies.
The same newsletter included a series of testimonials from participants about their positive outcomes from the â€œtherapyâ€ and â€œtreatment,â€ although it did not mention the trial arms by name. The newsletter did not balance these positive accounts by including any comments from participants with poor outcomes. At that time, about a third of the participantsâ€”200 or so out of the final total of 641–still had one or more assessments to undergo, according to a recruitment chart in the same newsletter.
â€œThe therapy was excellent,â€ wrote one participant. Another was â€œso happy that this treatment/trial has greatly changed my sleeping!â€ A third wrote: â€œBeing included in this trial has helped me tremendously. (The treatment) is now a way of life for me.â€ A fourth noted: â€œ(The therapist) is very helpful and gives me very useful advice and also motivates me.â€ One participantâ€™s doctor wrote about the â€œpositive changesâ€ in his patient from the â€œtherapy,â€ declared that the trial â€œclearly has the potential to transform [the] lives of many people,â€ and congratulated the PACE team on its â€œsuccessful programmeâ€â€”although no trial findings had yet been published.
Arthur Reingold, the head of epidemiology at the University of California, Berkeley, School of Public Health (and a colleague of mine), has reviewed innumerable clinical trials and observational studies in his decades of work and research with state, national and international public health agencies. He said he had never before seen a case in which researchers themselves had disseminated, mid-trial, such testimonials and statements promoting therapies under investigation. The situation raised concerns about the overall integrity of the study findings, he said.
Although specific interventions werenâ€™t named, he added, the testimonials could still have biased responses in all of the arms toward the positive, or exerted some other unpredictable effectâ€”especially since the primary outcomes were self-reported. (Heâ€™d also never seen a trial in which participants could be disabled enough for entry and â€œrecoveredâ€ on an indicator simultaneously.)
â€œGiven the subjective nature of the primary outcomes, broadcasting testimonials from those who had received interventions under study would seem to violate a basic tenet of research design, and potentially introduce substantial reporting and information bias,â€ said Reingold. â€œI am hard-pressed to recall a precedent for such an approach in other therapeutic trials. Under the circumstances, an independent review of the trial conducted by experts not involved in the design or conduct of the study would seem to be very much in order.â€
As soon as the Lancet article was released, Kindlon began sharing his impressions with others online. â€œIt was like a hive mind,â€ he said. â€œGradually people spotted different problems and would post those points, and you could see the flaws in it.â€
In addition to asserting that cognitive behavior therapy and exercise therapy were modestly effective, the Lancet paper declared these treatments to be safeâ€”no signs of serious adverse events, despite patientsâ€™ concerns. The pacing therapy proved little or no better than the baseline condition of specialist medical care. And the results for the two subgroups defined by other criteria did not differ significantly from the overall findings.
It didnâ€™t take long for Kindlon and the others to notice something unusualâ€”the investigators had made a great many mid-trial changes, including in both primary measures. Facing lagging recruitment eleven months into the trial, the PACE authors explained in The Lancet, they had decided to raise the physical function entry threshold, from the initial 60 to the healthier threshold of 65. With the fatigue scale, they had decided to abandon the 0 or 1 bimodal scoring system in favor of continuous scoring, with each answer ranging from 0 to 3; the reason, they wrote, was â€œto more sensitively test our hypotheses.â€ (As collected, the data allowed for both scoring methods.)
They did not explain why they made the decision about the fatigue scale in the middle of the trial rather than before, nor why they simply didnâ€™t provide the results with both scoring methods. They did not mention that in 2010, the FINE trialâ€”a smaller study for severely disabled and homebound ME/CFS patients that tested a rehabilitative intervention related to those in PACE–reported no significant differences in final outcomes between study arms, using the same physical function and fatigue questionnaires as in PACE.
The analysis of the Chalder Fatigue Scale responses in the FINE paper were bimodal, like those promised in the PACE protocol. However, the FINE researchers later reported that a post-hoc analysis, in which they rescored the Chalder Fatigue Scale responses using the continuous scale of 0 to 3, had found modest benefits. The following year, the PACE team adopted the same revised approach in The Lancet.
The FINE study also received funding in 2003 from the Medical Research Council, and the PACE team referred to it as its â€œsisterâ€ trial. Yet the text of the Lancet paper included nothing about the FINE trial and its negative findings.
Besides these changes, the authors did not include the promised protocol data: results forÂ â€œpositive outcomesâ€ for fatigue and physical function, and for the â€œoverall improversâ€ who achieved â€œpositive outcomesâ€ on both measures. Instead, noting that changes had been approved by oversight committees before outcome data had been examined, they introduced other statistical methods to assess the fatigue and physical function scores. All of their results showed modest advantages for cognitive behavior therapy and graded exercise therapy.
First, they compared the one-year changes in each armâ€™s average scores for physical function and fatigue. Yet unlike the method outlined in the protocol, this new mean-based measure did not provide information about a key factor of interestâ€”the actual numbers or proportion of participants in each group who reported having gotten better or worse.
In another approach, which they identified as a post-hoc analysis, they determined the proportion of participants in each arm who achieved what they defined as a â€œclinically usefulâ€ benefit–an increase of eight points on the physical function scale and a decrease of two points on the revised fatigue scale. Unlike the first analysis, this post-hoc analysis did provide individual-level rather than aggregate responses. Yet post-hoc results never enjoy the level of confidence granted to pre-specified ones.
Moreover, the improvements required for what the researchers now called a â€œclinically usefulâ€ benefit were smaller than the minimum improvements needed to achieve the protocolâ€™s threshold scores for â€œpositive outcomesâ€â€”an increase of ten points on the physical function scale, from the entry threshold of 65 to 75, and a drop of three points on the original fatigue scale, from the entry threshold of 6 to 3.
A third method in the Lancet paper was another post-hoc analysis, this one assessing how many participants in each group achieved what the researchers called the â€œnormal rangesâ€ for fatigue and physical function. They calculated these â€œnormal rangesâ€ from earlier studies that reported the responses of large population samples to the SF-36 and Chalder Fatigue Scale questionnaires. The authors reported that 30 and 28 percent of participants in, respectively, the cognitive behavior therapy and graded exercise therapy arms scored within the â€œnormal rangesâ€ of representative populations for both fatigue and physical function, about double the rate in the other groups.
Of the key objective measures mentioned in the protocol, the Lancet paper only included the results of the six-minute walking test. Those in the exercise arm averaged a modest increase in distance walked of 67 meters, from 312 at baseline to 379 at one year, while those in the other three arms, including cognitive behavior therapy, made no significant improvements, from similar baseline values.
But the exercise armâ€™s performance was still evidence of serious disability, lagging far behind the mean performances of relatively healthy women from 70 to 79 years (490 meters), people with pacemakers (461 meters), patients with Class II heart failure (558 meters), and cystic fibrosis patients (626 meters). About three-quarters of the PACE participants were women; the average age was 38.
In reading the Lancet paper, Kindlon realized that Trudie Chalder was highlighting the post-hoc â€œnormal rangeâ€ analysis of the two primary outcomes when she spoke at the PACE press conference of â€œtwice as manyâ€ participants in the cognitive behavior and exercise therapy arms getting â€œback to normal.â€ Yet he knew that â€œnormal rangeâ€ was a statistical construct, and did not mean the same thing as â€œback to normalâ€ or â€œrecoveredâ€ in medical terms.
The paper itself did not include any results for â€œrecoveryâ€ from the illness, as defined using the four criteria outlined in the protocol. Given that, Kindlon believed Chalder had created unneeded confusion in referring to participants as â€œback to normal.â€ Moreover, he believed the colleagues of the PACE authors had compounded the problem with their claim in the accompanying commentary of a 30 percent â€œrecoveryâ€ rate based on the same â€œnormal rangeâ€ analysis.
But Kindlon and others also noticed something very peculiar about these â€œnormal rangesâ€: They overlapped with the criteria for entering the trial. While a physical function score of 65 was considered evidence of sufficient disability to be a study participant, the researchers had now declared that a score of 60 and above was â€œwithin the normal range.â€ Someone could therefore enter the trial with a physical function score of 65, become more disabled, leave with a score of 60, and still be considered within the PACE trialâ€™s â€œnormal range.â€
The same bizarre paradox bedeviled the fatigue measure, in which a lower score indicated less fatigue. Under the revised, continuous method of scoring the answers on the Chalder Fatigue Scale, the 6 out of 11 required to demonstrate sufficient fatigue for entry translated into a score ranging from 12 and higher. Yet the PACE trialâ€™s â€œnormal rangeâ€ for fatigue included any score of 18 or below. A participant could have started the trial with a revised fatigue score of 12, become more fatigued to score 18 at the end, and yet still been considered within the â€œnormal range.â€
â€œIt was absurd that the criteria for â€˜normalâ€™ fatigue and physical functioning were lower than the entry criteria,â€ said Kindlon.
That meant, Kindlon realized, that some of the participants whom Chalder described as having gotten â€œback to normalâ€ because they met the â€œnormal rangeâ€ threshold might have actually gotten worse during the study. And the same was true of the Lancet commentary accompanying the PACE paper, in which participants who met the peculiar â€œnormal rangeâ€ threshold were said to have achieved â€œrecoveryâ€ according to a â€œstrict criterionâ€â€”a definition of â€œrecoveryâ€ that apparently survived the PACE authorsâ€™ pre-publication discussion of the commentaryâ€™s content.
Tom Kindlon wasnâ€™t surprised when these â€œback to normalâ€ and â€œrecoveryâ€ claims became the focus of much of the news coverage. Yet it bothered him tremendously that Chalder and the commentary authors were able to generate such positive publicity from what was, after all, a post-hoc analysis that allowed participants to be severely disabled and â€œback to normalâ€ or â€œrecoveredâ€ simultaneously.
Perplexed at the findings, members of the online network checked out the population-based studies cited in PACE as the sources of the â€œnormal ranges.â€ They discovered a serious problem. In those earlier studies, the responses to both the fatigue and physical function questionnaires did not form the symmetrical, bell-shaped curve known as a normal distribution. Instead, the responses were highly skewed, with many values clustered toward the healthier end of the scalesâ€”a frequent phenomenon in population-based health surveys.Â However, to calculate the PACE â€œnormal ranges,â€ the authors used a standard statistical methodâ€”taking the mean value, plus/minus one standard deviation, which identifies a range that includes 68% of the values in a normally distributed sample.
A 2007 paper co-authored by White noted that this formula for determining normal ranges â€œassumed a normal distribution of scoresâ€ and yielded different results given â€œa violation of the assumptions of normalityâ€â€”that is, when the data did not fall into a normal distribution. Whiteâ€™s 2007 paper also noted that the population-based responses to the SF-36 physical function questionnaire were not normally distributed and that using statistical methods specifically designed for such skewed populations would therefore yield different results.
To determine the fatigue â€œnormal range,â€ the PACE team used a 2010 paper co-authored by Chalder, which provided population-based responses to the Chalder Fatigue Scale. Like the population-based responses to the SF-36 questionnaire, the responses on the fatigue scale were also not normally distributed but skewed toward the healthy end, as the Chalder paper noted.
Despite Whiteâ€™s caveats in his 2007 paper about â€œa violation of the assumption of normality,â€ the PACE paper itself included no similar warnings about this major source of distortion in calculating both the physical function and fatigue â€œnormal rangesâ€ using the formula for normally distributed data. The Lancet paper also did not mention or discuss the implications of the head-scratching results: having outcome criteria that indicated worse health than the entry criteria for disability.
Bruce Levin, the Columbia biostatistician, said there are simple statistical formulas for calculating ranges that would include 68 percent of the values when the data are skewed and not normally distributed, as with the population-based data sources used by PACE for both the fatigue and physical function â€œnormal ranges.â€ To apply the standard formula to data sources that have highly skewed distributions, said Levin, can lead to â€œvery misleadingâ€ results.
Raising tough questions about the changes to the PACE protocol certainly conformed to the philosophy of the journal that published it. BioMed Central, the publisher of BMC Neurology, notes on its site that a major goal of publishing trial protocols is â€œenabling readers to compare what was originally intended with what was actually done, thus preventing both â€˜data dredgingâ€™ and post-hoc revisions of study aims.â€ The BMC Neurology â€œeditorâ€™s commentâ€ linked to the PACE protocol reinforced the message that the investigators should be held to account.
Unplanned changes to protocols are never advisable, and they present particular problems in unblinded trials like PACE, said Levin, the Columbia biostatistician. Investigators in such trials might easily sense the outcome trends long before examining the actual outcome data, and that knowledge could influence how they revise the measures from the protocol, he said.
And even when changes are approved by appropriate oversight committees, added Levin, researchers must take steps to address concerns about the impacts on results. These steps might include reporting the findings under both the initial and the revised methods in sensitivity analyses, which can assess whether different assumptions or conditions would cause significant differences in the results, he said.
â€œAnd where substantive differences in results occur, the investigators need to explain why those differences arise and convince an appropriately skeptical audience why the revised findings should be given greater weight than those using the a priori measures.â€ said Levin, noting that the PACE authors did not take these steps.
Some PACE trial participants were unpleasantly surprised to learn only after the trial of the researchersâ€™ financial and consulting ties to insurance companies. The researchers disclosed these links in the â€œconflicts of interestâ€ section of the Lancet article. Yet the authors had promised to adhere to the Declaration of Helsinki, an international human research ethics code mandating that prospective trial participants be informed about â€œany possible conflicts of interestâ€ and â€œinstitutional affiliations of the researcher.â€
The sample participant information and consent forms in the final approved protocol did not include any of the information. Four trial participants interviewed, three in person and one by telephone, all said they were not informed before or during the study about the PACE investigatorsâ€™ ties to insurance companies, especially those in the disability sector. Two said they would have agreed to be in the trial anyway because they lacked other options; two said it would have impacted their decision to participate.
Rhiannon Chaffer said she would likely have refused to be in the trial, had she known beforehand. â€œIâ€™m skeptical of anything thatâ€™s backed by insurance, so it would have made a difference to me because it would have felt like the trial wasnâ€™t independent,â€ said Chaffer, in her mid-30s, who became ill in 2006 and attended a PACE trial center in Bristol.
Another of the four withdrew her consent retroactively and forbade the researchers from using her data in the published results. â€œI wasnâ€™t given the option of being informed, quite honestly,â€ she said, requesting anonymity because of ongoing legal matters related to her illness. â€œI felt quite pissed off and betrayed. I felt like they lied by omission.â€
(None of the participants, including three in the cognitive behavior therapy arm, felt the trial had reversed their illness. I will describe these participantsâ€™ experiences at a later point).
Tomorrow: The Aftermath
Is this Part Two? It’s entitled “Part Three”.
John Peters says
It’s the second installment to be uploaded and contains part three of the whole paper. An introduction and parts one and two were in the first installment here: https://t.co/S5NIWNHLt4
Yesterday’s was a first installment containing parts 1 and 2, so we continue with part 3, in the second instalment 🙂
My bad! Thanks, Firestormm.
“In addition to asserting that cognitive behavior therapy and exercise therapy were modestly effective, the Lancet paper declared these treatments to be safeâ€”no signs of serious adverse events, despite patientsâ€™ concerns.”
I am still frustrated by this assertion by the Lancet. Unless I missed something in my read-throughs of the initial paper and the follow-ups, the only reason there were no signs of serious adverse events was because the PACE trial didn’t analyse the data in a way that would flag up adverse events. But as the old saying goes, an absence of evidence is not evidence of absence!
We know several participants dropped out – but there’s no data on why. It could be totally unrelated to the trial, or it could be that carrying out the trial protocols had caused illness flare-ups that left them unable to carry on.
We know that a portion of the particiants didn’t improve under their assigned treatment – but there’s no data available on what proportion of those participants maintained a stable level of health (no better, but no worse either), and what proportion found that their health actively worsened whilst maintaining the trial treatment. There’s also no data on how great the loss of health was in participants whose level of health got worse.
Thank you, David and Vince, for another instalment in this sorry tale.
As Dr Bruce Levin (the biostatistician at Columbia University whom you quote) says, once an open-label trial is underway, it’s too late to introduce changes to your analyses because it’s too late to protect against post-hoc bias: in the PACE trial, it would have been very hard for the authors to avoid getting a sense that patients in the trial were doing poorly overall.
And if you lower all of your recovery thresholds to nonsensical levels partway through – as the PACE trial authors did – then it’s obviously going to artificially boost your recovery rates. And if you send a newsletter to your patients telling them that government-backed guidelines recommended CBT and GET – as the PACE trial authors did – then you have a recipe for boosting patients’ self-ratings in the CBT and GET groups and for selectively inflating “recovery” rates in those groups.
The changes to the analyses bring the integrity of the trials’ analyses into serious question, as anyone with knowledge of the normal standards of clinical trial conduct would agree.
It is imperative that the PACE trial authors now release the results of the recovery analyses according to the original criteria that were specified in the study protocol.
Failure to do this so far reflects very poorly on every co-author who signed off on that paper, on the Medical Research Council who funded the study, and on Queen Mary, University of London, who appear to be refusing perfectly reasonable Freedom of Information requests for these analyses. I wonder if they have any real understanding of what they’re doing.
I think that scientists who aren’t familiar with the PACE story are going to be very shocked at what they’re reading here.
Thank you for this, and also, for making it a bit shorter. Yesterday’s was a lot to take in at once.
Having said that, I thought I’d post some additional information that may be of interest to readers. If you look at the PACE trial’s manuals (http://www.wolfson.qmul.ac.uk/current-projects/pace-trial#trial-information), there are lots of other examples of information being given to participants as a part of the trial, other than the leaflet including patient’s testimonials, which would seem likely to risk biasing results.
For example, in the GET participant’s manual it states:
“Thinking ability (cognition) Graded Exercise Therapy for CFS/ME has been shown to improve thinking ability, or cognition.
In previous research studies, most people with CFS/ME felt either â€˜much betterâ€™ or â€˜very much betterâ€™ with GET.
Exercise has been considered a useful strategy for many years in the rehabilitation of fibromyalgia, Multiple Sclerosis, and many other neurological conditions. Research has now shown that carefully graded exercise (Graded Exercise Therapy) can also be a very helpful therapy for CFS/ME. You may be aware that the Chief Medical Officerâ€™s Report of 2002 recommended GET as one of the most effective therapy strategies currently known.”
In the CBT participant’s manual:
“Many of the strategies described in the manual are based on cognitive behaviour
therapy, which has been shown to be effective in treating a wide range of problems,
Cognitive behaviour therapy (CBT) is a powerful and safe treatment which has been
shown to be effective in a variety of illnesses, including CFS/ME, headaches and back
I couldn’t see equivalent claims in the information provided to those not receiving CBT or GET.
CBT is described like this:
The essence of CBT is helping the participant to change their interpretation of
symptoms and associated fear, symptom focussing and avoidance. Participants are
encouraged to see symptoms as temporary and reversible and not as signs of harm or evidence of fixed disease pathology. In this way it is anticipated that they will gain more control of their lives, as they, and not their symptoms, dictate what they do.”
Assessing an intervention like this via self-report is not sensible, even ignoring problems with the way in which PACE then presented these results. Being able to manage patient cognitions in a way which leads to these sorts of minor improvements in questionnaire scores is not the same as providing an effective treatment.
Cort Johnson says
Given the voluminous problems in the trial cited here and the other article it’s clear that Lancet should reassess this paper. How can we as a community best support that happening?
The Lancet went all in with their defence of PACE. Even their coverage of the IOM report claimed that PACE had (somehow) led to it. Horton was very condemning of those questioning PACE. If it’s accepted that people’s concerns were justified then this will be very embarrassing for the administration at the Lancet.
I agree, Cort – The Lancet should be looking at their paper and so should Psychological Medicine, who published the 2013 paper that reported the “recovery” figures.
How to get that to happen is a key question, since the very fact that it’s patients who have raised concerns about PACE’s methodology in the past seems to have been enough to get those concerns dismissed.
That’s why we should all be particularly grateful to David Tuller, as an academic who has been willing to step forward and lend his weight, and to the prestigious researchers whom he quotes to such devastating effect in his article.
So yes, excellent question: how can we as a community – and the scientists and others who want to see good-quality research – get The Lancet and Psychological Medicine to fulfil their responsibilities?
Good point. Serious Adverse Events (SAEs) had to last for a couple months or result in hospitalization or death. Non-Serious Adverse Events (NSAEs) could cover anything from feeling a little more tired than usual up to weeks of being completely bedbound. With those definitions, and the actometers being dumped in the trash, they managed to very effectively avoid any risk of detecting the core symptom of ME/CFS, post-exertional malaise.
And of course, they unblinded the trial arm of any participant experiencing an SAE or NSAE before deciding if it was a reaction to the treatment. Shockingly (or maybe not), an increased rate of SAEs in the GET trial completely disappeared after that unblinding, and the researchers could smugly report no increase in serious adverse reactions, based on their opinion that the SAE could not possibly be a reaction to their favored treatments.
Erik Johnson says
“Komaroff ways test results reveal an attack on the immune system’s “natural killer cell”, which is the bodies primary means of killing virus-infected cells or cells that become cancerous”
Erik Johnson says
I don’t get the sense that they believe their “CFS” has anything to do with the original CFS.
James David Chapman says
Cort Johnson, that is a very good question!
I am sure M.E patients read David Tuller’s article for its thorough discussion of the scientific flaws within the PACE trial. Many British doctors will, however, be most deeply hurt by the professional criticism contained within the quotes from well-respected members of the medical and scientific community. Sadly, I think these will be the most effective agent for change here and I hope more scientists can be encouraged to make plain their dismay. Patients need to find allies in all disciplines and to gain more and more publishable quotes. This is now not simply a fight for good treatment within M.E but a part of a much-needed drive towards a higher standard of scientific research in general.
From personal experience, I think it will be more effective for patients to talk to *everyone other than The Lancet* than to apply pressure directly. If British medicine itself will not listen, again, other scientific disciplines within Britain should be contacted for aid (via journals, personal contacts etc). Worldwide scientific sceptic movements should also be encouraged to challenge PACE (with same the gusto, we hope, as they would when challenging complimentary medicine or when debunking pseudo-science).
It is well past time UK M.E patients required their charities make clear their position on whether the PACE trial is good science. Funding is a major problem in M.E and we simply cannot afford to support charities and researchers who cannot see, or feel they cannot talk about, the errors in our previous, unsuccessful & heavily biased approach.
The UK CFSME Research Collaborative bans personal attacks between members, however the problems in PACE are so extreme it is hard to challenge the science of the research without appearing to impugn its authors. Be that as it may, to maintain its credibility, the UK CFSME Research Collaborative must encourage a thorough questioning of the PACE trial for we cannot safely build on such a foundation. At #CMRC2015, a reasonable PACE question posed by a patient organisation via Twitter was not passed on by a member as it was deemed â€œnegative towards specific researchâ€. This is a truly worrying development and patients and patient groups need to ensure that their voice is both heard and actually counts for something.
Politics seems often to be about maintaining equivocal positions on matters, (to maintain power and flexibility and so as not to alienate and lose support). Science however is about truth, judgement and fact. A clear and honest approach is the only way we can ever hope to make progress within M.E. It is well past time M.E patients demanded straight answers to the straight questions we have posed for decades.
People with M.E need Rest, Research and Respect. …Onward! 😀
Guido den Broeder says
In their statistical calculations, they also compared Standard Care to Standard Care + CBT, and so on, without taking possible correlations into account.
The more I read this, the more it reminiscent of an Emporer’s new clothes situation.
Maybe if another prominent researcher held a major GET/CBT study using objective outcome measures and realistic recovery definitions such as return to work and normal exercise tolerance, the Lancet might notice.
It would be unethical, probably, but there are such few studies contradicting PACE.
The published work of other scientists brought Science to retract Lombardi XMRV paper.
Guido den Broeder says
To accomplish anything, at all, ‘we’ must first learn that the ME community is not the CFS community. ME is not involved in the PACE trial, even the authors have said this. Pretending that it’s about ME hurts the cause of the ME community. So don’t do it.
That study has already been done, cluecat, and it’s the PACE trial. Those objective measures were used in the PACE trial and show that the therapies don’t work, but the study authors now choose to dismiss them, even though they were the ones who chose them in the first place.
No need to waste money and risk more patients’ health by running another trial.
Sasha, unfortunately the Lancet is unconvinced that the PACE trial’s limited objective results are sufficient to retract the study. If that were true, the many letters including those of Tom Kindlon and other advocates to the Lancet would have initiated a review process.
The step test results shows the GET improves physical functioning to a modest degree (likely, patients able to improve were functioning below their threshold at the start of the trial), though like the author stated remain well below that of other illnesses in addition to the problem of patient selection potentially skewing results.
Hi cluecat – I think the point is, as you mention, that the step test results are so spectacularly short of normal that they show that there’s very little effect demonstrated by the therapies.
My impression is that The Lancet – and others – need a bit of a jolt to realise that they shouldn’t discount criticisms just because it’s patients who have been making them and that they should start paying attention to the actual criticisms themselves.
Now that heavyweights such as Prof. Jonathan Edwards and Dr Ronald Davis and others are weighing in and not pulling their punches, I hope they’ll realise their mistake and start doing their jobs.
David Tuller and Vince Racaniello have done a great thing here in raising the profile of these criticisms enormously. This is now all over the internet in a way that it wasn’t previously.
I hope that The Lancet, Psychological Medicine, the MRC and Queen Mary, University of London will now start acting responsibly and in the interests of patients, as they should have been doing all along.
This whole situation is shameful for them.
Beatrice Pham says
In fact, there is one such study — by Nunez in Spain — that showed a combination of GET/CBT compared to usual care worsened the physical function and pain levels significantly, as measured by the same instrument – Sf-36, in the intervention group. But this trial is rarely referred to as it contradicts the “prevailing” idea the GET/CBT works.
“At 12 months, the intervention did not improve HRQL scores, with worse
SF-36 physical function and bodily pain scores in the intervention
group. Multidisciplinary treatment was not superior to usual treatment
at 12 months in terms of HRQL. The possible benefits of GET as part of
multidisciplinary treatment for CFS should be assessed on an individual
Thanks to David Tuller for writing the article and Vincent Rancanciello for hosting it.
Re-reading through your quotes from the GET participants’ manual, it struck me that they’re asserting that the value of the treatment has been proven…in the trial designed to test whether the treatment can be proven valuable.
That’s an…interesting…definition of scientific proof. Wow.
One correction – it was the 6 minute walking test (6MWT) where GET showed some improvement, not the step test. And the 6MWT improvement compared to the other arms was too small to reach clinical significance.
Yet when the papers constructed headlines using ME no-one from the PACE trial corrected them. ME patients in the UK have been badly harmed by the headlines from the various PACE releases.
ME/CFS make it apply or imply that it is about ME. It is not. Tuller seems to want to promote the ME/CFS agenda.
james it seems what you are suggesting is that pwmes sit back and watch the scientists duke it out. how else can patients take direct action? this is seems to be an ongoing theme in our community: most of us agree on what needs to be done but no one knows how to get there.
Due to ME/CFS, not PACE.
Hallo Valentijn. You might remember me. This literature is so important and interesting that I have been doing little else except reading and conversing about it. I feel strongly that this is suitable to change clinical procedure.
patrick holland says
shh, shh, shh, quiet, Erik you might upset Dr. Charles Shepherd, as he says there are no biomarkers and no biological evidence and no proofs, and no tests, as he is in bed with wessely, white and sharpe.
patrick holland says
Thanks David Tuller. What do we do with this information ? whats the next step ? patients have been waiting for many years and decades and nothing has happened !
Do you really want change and progress ? There should be enough evidence now for patients to bring legal actions and court actions and government actions against these “researchers” and challenge them directly. Some people have proposed plans for this
patrick holland says
In Britain the sirs, the lords, the ladies and the dukes have been skewing evidence, lying and deceiving for centuries. And the sheep, including some doctors believe everything they are told. Its nothing new.