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Work 66 (2020) 283–308DOI:10.3233/WOR-203174IOS Press
Graded exercise therapy does not restorethe ability to work in ME/CFS – Rethinkingof a Cochrane review
Mark Vinka,∗ and Friso Vink-NiesebaFamily and Insurance Physician, Amsterdam, The NetherlandsbIndependent Researcher, Germany
Received 12 November 2019Accepted 14 January 2020
Abstract.BACKGROUND: Cochrane recently amended its exercise review for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome(ME/CFS) in response to an official complaint.OBJECTIVE: To determine if the amended review has addressed the concerns raised about the previous review and ifexercise is an effective treatment that restores the ability to work in ME/CFS.METHOD: The authors reviewed the amended Cochrane exercise review and the eight trials in it by paying particular interestto the objective outcomes. We also summarised the recently published review of work rehabilitation and medical retirementfor ME/CFS.RESULTS: The Cochrane review concluded that graded exercise therapy (GET) improves fatigue at the end of treatmentcompared to no-treatment. However, the review did not consider the unreliability of subjective outcomes in non-blindedtrials, the objective outcomes which showed that GET is not effective, or the serious flaws of the studies included in thereview. These flaws included badly matched control groups, relying on an unreliable fatigue instrument as primary outcome,outcome switching, p-hacking, ignoring evidence of harms, etc. The review did also not take into account that GET does notrestore the ability to work.CONCLUSION: GET not only fails to objectively improve function significantly or to restore the ability to work, but it isalso detrimental to the health of ≥50% of patients, according to a multitude of patient surveys. Consequently, it should notbe recommended.
Keywords: Bias, occupational health, patient safety, return to work, work rehabilitation
The Cochrane exercise review by Larun et al.for Myalgic Encephalomyelitis/Chronic Fatigue Syn-drome (ME/CFS) was published in 2015 . This
∗Address for correspondence: Mark Vink, Family and Insur-ance Physician, Amsterdam, The Netherlands. E-mail: [email protected]: http://orcid.org/0000-0003-1079-5647
triggered responses from a number of people, mostnotably Kindlon and Courtney [2, 3]. In their replies,the reviewers did not address the concerns that wereraised. Consequently, Courtney lodged a formal com-plaint . He discussed a number of problems withthe review which led him to determine that the authorscame to an incorrect conclusion. An independentreview of the Cochrane exercise review was published in October 2018, in which the authors confirmed
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284 M. Vink and F. Vink-Niese / Graded exercise therapy does not restore the ability to work in ME/CFS
the concerns raised by Kindlon, Courtney and others,namely, that the studies in the Cochrane review exhib-ited serious problems that extended to the Cochranereview itself.
According to that independent review, theCochrane review not only ignored those problems butalso ignored the objective outcomes which showedthat exercise therapy does not lead to significantobjective improvements in patients with ME/CFS. InOctober 2019, in response to the complaint by Court-ney, Larun et al. published an amended Cochraneexercise review . In this article, we will sum-marise and review this, to determine if the reviewersadequately addressed the concerns of Kindlon, Court-ney and the aforementioned independent review. Thisdetermination is vital as the Cochrane review is animportant document for patients and doctors world-wide.
We also intend to summarise the recently publishedreview of work rehabilitation and medical retirementfor ME/CFS . We will focus on the most importantthings in both papers - with regards to occupationaltherapists, occupational health doctors and othersinvolved in rehabilitation of ME/CFS patients - toanswer the following questions:
• Should ME/CFS patients be treated with GET?• Is GET safe to use in ME/CFS?• Does GET lead to clinically significant objective
improvements?• Does GET restore the ability to work in
2. The amended Cochrane exercise review
According to Larun et al., “Chronic fatigue syn-drome (CFS) or myalgic encephalomyelitis (ME) isa serious disorder characterised by persistent pos-texertional fatigue and substantial symptoms relatedto cognitive, immune and autonomous dysfunction.”“The review included eight randomised controlled tri-als (RCTs) with data from 1518 participants (adults)with a primary diagnosis of CFS, from all diagnos-tic criteria, who were able to participate in exercisetherapy.” The reviewers concluded that: “Most stud-ies had a low risk of selection bias. Exercise therapyprobably has a positive effect on fatigue in adultswith CFS and they may have moderately better phys-ical functioning [at the end of treatment] comparedto usual care or passive therapies. The evidenceregarding adverse effects is uncertain. All studies
were conducted with outpatients diagnosed with 1994criteria of the Centers for Disease Control and Preven-tion or the Oxford criteria, or both. Patients diagnosedusing other criteria may experience different effects”.
It is important to note that persistent post-exertional fatigue is not the main characteristic of thedisease. ME/CFS is most commonly characterisedby post-exertional malaise (PEM). The prestigiousAmerican Institute of Medicine (IOM, now theNational Academy of Medicine), defined PEM asan exacerbation of some or all of an individual’sME/CFS symptoms that occurs after physical orcognitive exertion and leads to a reduction in func-tional ability. The IOM concluded that ME/CFS isa systemic exertion intolerance disease . Mod-ern diagnostic criteria of ME/CFS, like the Canadianconsensus criteria from 2003 , or the interna-tional consensus criteria from 2011 , requirepost-exertional malaise to be present in order to bediagnosed with the illness.
2.1. Selection criteria
Despite concerns identified by Kindlon and Court-ney [2, 3], the Cochrane review relied on studiesknown for using poor selection criteria. Three stud-ies in the review used the 1994 CDC criteria, oftenreferred to as the Fukuda criteria (Jason et al.,2007; Moss-Morris et al. 2005; Wallman et al., 2004[11–13], and the five other studies used the Oxfordcriteria (Fulcher and White, 1997; Powell et al., 2001;Wearden et al., 1998; Wearden et al., 2010; White etal., 2011 [14–18]. The only criterion according to theOxford criteria, is six months or more of chronic dis-abling fatigue . The Fukuda criteria also requirefour or more of eight specified other symptoms .PEM, the main characteristics of the disease, is not arequirement according to the Oxford criteria and onlyan optional requirement according to the Fukuda cri-teria. In a study by Friedberg et al. , 15% of peoplelabelled by the Fukuda criteria as having ME/CFS,were in fact healthy people. Baraniuk  foundthat the Oxford criteria inappropriately select healthysubjects with mild or chronic idiopathic fatigue andmislabel them as ME/CFS. A report commissioned bythe American National Institute of Health (NIH), con-cluded in 2014 that the Oxford criteria are flawed andlead to the inclusion of people with other conditions,confounding the ability to interpret the science .That report stated that: “Continuing to use the Oxforddefinition may impair progress and cause harm” [23,
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24]. The Agency for Healthcare Research and Quality(AHRQ) stated in 2016 that “using the Oxford casedefinition results in a high risk of including patientswho may have an alternate fatiguing illness or whoseillness resolves spontaneously with time” . Boththe NIH and AHRQ recommend that the Oxford def-inition should be retired.
The use of the Oxford and the Fukuda criteria bythe eight studies of the review, means that it is likelythat these studies included patients who did not haveME/CFS. Because of these challenges with the selec-tion criteria, the conclusions of the Cochrane revieware questionable.
2.2. Problems with the controls
According to the Cochrane review , there wasa problem with matching in Jason et al. (2007) ,because the relaxation group (RELAX) had a highermean physical functioning score at baseline than theanaerobic activity group (ACT), 53.77 versus 39.17.However, the objective 6-minute walk test results atbaseline were very similar: 1335 (ACT) versus 1317(RELAX; higher scores indicating better outcome).
But in five of the other eight studies, the reviewignored the fact that the control groups were notevenly matched. For instance, in Wearden et al.(1998) , there was a difference in age between theexercise and placebo drug group (40.4) and the exer-cise placebo and placebo drug group (37.6); in illnessduration (34.5 and 22.0 months) and fitness accordingto the oxygen uptake during cardiopulmonary exer-cise testing (CPET; 19.9 versus 26.0 for the treatmentand control group respectively).
In Fulcher and White (1997) , there was a dif-ference in physical fatigue on the visual analoguescale with scores of 161 (GET) and 177 (flexibility)and oxygen consumption scores during CPET (31.8versus 28.2 flexibility); the Chalder fatigue scoreswere 28.9 and 30.5 at baseline and the SF 36 gen-eral health scores were 41 and 33 for exercise andflexibility respectively. This indicates that the partici-pants in the flexibility control group had worse fitnessand physical health than participants in the treatmentgroup. Also, the oxygen consumption scores in theexercise group indicate that participants in this grouphad normal fitness at baseline.
In Moss-Morris et al. (2005) , there were bigdifferences in mean age (36.7 exercise versus 45.48control); illness duration (2.67 years exercise versus5.0 years control) and physical functioning scores(53.1 exercise versus 45.65 control).
In Wearden et al. (2010) , there was a signif-icant difference in comorbidities: 44.2% (treatment)and 33.7% (no-treatment) had no comorbidities and33.0% (treatment) and 43.0% (no-treatment), had twoor more comorbidities. In White et al. (2011) ,there was a difference in quality of life between theadaptive pacing (APT) control group (0.48) and GET(0.52). This suggests that the APT group was moredisabled.
The control groups in a number of trials werein reality no-treatment control groups. No-treatmentwas labelled standard medical care in Moss-Morris etal. (2005) , general practitioner treatment as usualin Wearden et al. (2010) , specialist or standard-ised medical care (SMC) in Powell et al. (2001) and White et al. (2011)  and exercise placeboin Wearden et al. (1998) . These studies hadnot organised regular comparison treatment wherepatients would receive the same number of sessions,the same care and attention etcetera, from practition-ers who were as positive about their control treatmentas the practitioners would be in the treatment group.Assignment to ‘no-treatment’ may strengthen partic-ipants’ beliefs that they will not improve, therebyreducing the chance of spontaneous improvement. White et al. (2011)  documented therapeuticalliance and adherence to manual. Figures were pro-vided for both questions for APT, CBT and GET yetno figures were provided for SMC, confirming thatSMC was a no-treatment control group.
In conclusion, in five of the eight trials, there wasa significant difference in level of disability betweenparticipants in the treatment groups and those in thecontrol groups. Also, instead of receiving a controltreatment, in most trials they received no-treatment.In view of these problems, one cannot safely concludethat GET is an effective treatment.
2.3. GET definition challenges
There were additional concerns about the defini-tions of GET and pacing in Wallman et al. (2004). The researchers stated that they studied GET andpacing, which they described in the following man-ner. “Subjects choose walking, cycling or swimming.Subjects were instructed to exercise every secondday, unless they had a relapse. If this occurred, orif symptoms became worse, the next exercise sessionwas shortened or cancelled. Subsequent exercise ses-sions were reduced to a length that the subject feltwas manageable. This form of exercise, which allowsfor flexibility in exercise routines, is known as pac-
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Table 1Potential forms of bias in the trials
Study Crit % of Blinded Researchers Objective Protocol Changes All ItT analysis Participantscreened study alliance to primary/ published/ to protocol outcomes performed newsletterpatients the secondary published after the reported or manualselected treatment outcomes before the start of used to
used start of the trial promotethe trial treatment
Fulcher andWhite(1997) 
Ox 39.5% (66/167) No Yes No/yes No –– ? Yes No
Jason et al.(2007) 
FuC 100% (114/114) No No No/yes No –– ? No No
Moss-Morriset al. (2005)
FuC 96.1% (49/51) No Yes No/yes No –– ? Yes No
Powell et al.(2001) 
Ox 47.4% (148/312) No Yes No No –– ? Yes No
Wallman et al.(2004) 
FuC 82.9% (68/82) No Yes No No –– ? No No
Wearden et al.(1998) 
Ox 59.9% (136/227) No Yes No No –– ? Yes No
Wearden et al.(2010) [17,28]
Ox 65.9% (296/449) No Yes No/yes Yes/no Yes No Yes Yes
White et al.(2011) [18,29]
Ox 20.3% (641/3158) No Yes No/yes Yes/no Yes No Yes Yes
Crit: criteria; FuC: Fukuda criteria; ItT: intention to treat; Ox: Oxford criteria.
ing.” In graded exercise therapy for ME/CFS, plannedphysical activity and not symptoms dictate what par-ticipants do . Wallman et al. was therefore a studyof pacing and not one of graded exercise and pacing.
Larun et al.  report that selection bias in thestudies they included is low. Selection bias is thebias introduced by how participants are selected andwho researchers include or exclude from their studies. It is also introduced when a large percentage ofpatients who are eligible for a study are not includedin it. In this manner, a study could select partici-pants who the researchers think are the most likelyto benefit from their intervention. This was a partic-ular problem in the PACE trial by White et al.(2011) and Fulcher and White (1997) , which bothused the very wide and not well defined Oxford cri-teria; only 20.3% (640/3158) and 39.5% (66/167) ofthe screened participants, respectively, were selectedas can be seen in Table 1. This table also shows anumber of other forms of bias in the studies.
Three studies (Fulcher and White, 1997; Jasonet al., 2007; Moss-Morris et al., 2005) [11, 12, 14]did not have entry score requirements. In Wear-
den et al. (1998)  entry requirements were suchthat relatively high-functioning participants could beincluded as they used a physical functioning entryscore of up to 83.3, whereas a score of 84 is the meanscore for the UK working age population according toWhite et al. (2011)  (0–100, high score meaningbetter physical functioning). In Powell et al. (2001), a physical functioning entry score of up to 24(included, which corresponds to a score of 70 on thescale of 0–100 ) out of 30 was used. This is barelybelow the score of 25 (equivalent to 75) or more - animprovement on just one of the 20 questions/items -which was used to deem the study’s treatment suc-cessful. Only three studies (Wearden et al., 1998;Wearden et al., 2010; White et al., 2011) [16–18] hadentry requirements for fatigue even though fatiguewas a primary outcome of most studies included inthe Cochrane review.
Further questions about selection bias are raisedin Moss-Morris et al. (2005) , where 77.6% ofpatients were well enough to be in work. But also inboth Fulcher and White (1997)  and Moss-Morriset al. (2005) , where participants already hadnormal objective mean physical functioning/fitnessscores at trial entry as was found by the reanaly-sis of the Cochrane exercise review . Moreover,
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Moss-Morris et al. (2005)  had a biased sample:participants were from a private clinic and had con-tacted the university, so were self-selected just like theparticipants in Jason et al. (2007) . These partici-pants were thus invested in the trial and more likely tobelieve in the possible effectiveness of the interven-tion. But at the same time, contrary to most ME/CFSpatients, they were also less likely to have problemswith exercise, because if they had, it is unlikely thatthey would have volunteered for an exercise study.
2.4.1. Selective reporting (reporting bias)126.96.36.199. p-hacking and endpoint changes. Accord-ing to the Cochrane review , “Wearden 2010and White 2011 referenced published protocols. Wechecked these against the published results, and foundthat reporting was adequate and that the risk of biaswas low.”
Wearden et al. (2010) is more commonly knownas the FINE trial (FINE: Fatigue Intervention byNurses Evaluation). The entry criteria of this trialwere changed from the Fukuda to the even widerOxford criteria, eight months into a four-year longtrial. No reason was given . According to theFINE trial protocol , primary outcomes were to beself-reported physical functioning and fatigue at oneyear. Yet in the 2010 paper, the outcomes at 20 weeks(end of treatment) were added and were suddenly themost important ones. The reason for this might bethat the fatigue outcome at 70 weeks showed a nulleffect.
Further, the FINE trial’s fatigue scores werechanged from bimodal (0–11) to Likert (0–33) afterthe 2010 paper was published, in a Rapid Responsein the BMJ  and in their economic analysis .This change was made despite the fact that two ofthe authors (including the Principal Investigator) con-cluded in a paper, devoted to analysing the use ofthe Chalder Fatigue scale in ME/CFS , that near-maximal scoring on six physical fatigue scale itemsfrom the total of 14 items (five if the 11 item scaleis used) supports using the two-point bimodal, ratherthan the four-point Likert scoring. Once re-scored,there was now a clinically modest, but statisticallysignificant, effect of pragmatic rehabilitation com-pared with no-treatment at both outcome points.However, altering measures in this way after the trialto find a small effect suggests a form of p-hacking.This is a type of bias which “occurs when researcherscollect or select data or statistical analyses until non-significant results become significant” .
White et al. (2011)  is better known as thePACE trial (PACE: Pacing, Activity, and Cognitivebehaviour therapy: a randomised Evaluation). TheCochrane review  notes that some readers claimthat the study should be viewed as a post hoc studybecause “The protocol and the statistical analysis planwere not formally published prior to recruitment ofparticipants.” They also note that “The study authorsoppose this, and have published a minute from a TrialSteering Committee (TSC) meeting stating that anychanges made to the analysis since the original pro-tocol was agreed by TSC and signed on before theanalysis commenced.” Because of this, the Cochranereview concluded that there was a low risk of selec-tive reporting in this trial. However, as Evans notedin his article on changing endpoints after the start of aclinical trial, “A fundamental principle in the designof randomized trials involves setting out in advancethe endpoints that will be assessed in the trial, as fail-ure to prespecify endpoints can introduce bias into atrial and creates opportunities for manipulation” .Moreover, the PACE trial involved the recruitmentof “641 participants” “between March 18, 2005, andNov 28, 2008”  and according to a Freedom ofinformation request , the approval by the TSC, asmentioned by the Cochrane reviewers, was given on4 September 2009. This means that the researchershad ample time to have a look at the results of mostor all of the participants before this date. Finally, itwas a non-blinded trial and researchers in such trialsusually have a good indication of how participantsare responding to the treatments under investigation,even if they do not look at the data.
188.8.131.52. Not publishing and/or ignoring objectiveoutcomes. The FINE trial’s only objective (sec-ondary) outcome measure (step test) was omittedfrom the 2010 paper, even though not publishingresults jeopardizes the validity of a study . Thestep test results were published three years later and they showed that there were no objective differ-ences between exercise (pragmatic rehabilitation orPR) and no-treatment.
In the PACE trial, baseline figures were capturedfor one objective test, the actometer, a reliable mea-sure of activity to assess improvement objectively, but were not recorded at the end of the trial.According to the PACE trial researchers, that wouldhave been too great a burden  for patients, eventhough they had consented to use the actometer beforeand after treatment. On top of this, participants hadcompleted moderately effective treatment according
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to the trial itself ; around 60% of those in the CBTand GET groups had substantially improved and 22%had actually recovered according to the researchers. Consequently, it would have been more of aburden at the beginning than at the end of the PACEtrial.
Also, the PACE trial’s step test results were notpublished in the original 2011 paper. The researcherswaited till 2015 to publish a figure labelled fitness,depicting the outcome and they wrote the follow-ing about it: “There were no effects on...physicalfitness” . In other words, the step test showedthat CBT and GET did not lead to objective improve-ment. The mean fitness scores, however, have still notbeen published and the investigators refuse to releasethe individual data of the step test.
184.108.40.206. Overlap in entry and recovery criteria. Animportant problem of the PACE trial is that the investi-gators made an extensive number of endpoint changesas mentioned before [18, 40, 43, 44]. As a result therewas suddenly an overlap in entry and recovery crite-ria. Consequently, 13.3% of participants were alreadyrecovered, according to one (12.8%) or two (0.5%) ofthe recovery criteria, at trial entry - before receivingany treatment .
These changes affected both the physical functionscores (PF) and the fatigue scores. The minimumPF required to qualify as recovered was reducedfrom 85 to 60 , even though a score of 65 orless represents “abnormal levels of physical func-tion” according to the PACE trial’s own recoveryarticle . The maximum score for trial entry wasincreased from 60 to 65 (0–100; higher scores indi-cating better functioning). Participants with a score of60 to 65 (inclusive) were thus considered ill enoughto participate, to have an abnormal level of physi-cal functioning, and be severely disabled accordingto the literature . Yet at the same time, with thesame physical function scores, they were also recov-ered according to the PACE trial’s recovery article. One cannot be severely disabled and recov-ered at the same time. Moreover, three participants(0.45%) saw their physical functioning score go downfrom 65 to 60, reflecting deterioration, and threeothers (0.45%) had unchanged physical functioningscores, but all (0.9%) were still classed as recovered,according to the physical functioning recovery cri-terion . Clearly, this classification of recovery -even when patients had no change or negative changefrom baseline, or when they were still severely dis-abled - could lead to misleading conclusions. For
example, newspapers, doctors and medical guidelinescould conclude that patients can talk and exercisetheir way out of this illness, when in reality, the PACEtrial’s own data shows that this is not the case and anincorrect conclusion.
A similar misclassification happened to the fatiguescores. When PACE was registered with the ISRCTNon 22 May 2003, participants needed a ChalderFatigue Scale (ChFS) score of four or more to beclassed as ill enough to take part . The ChFSentry criterion was changed to six or more beforethe trial started and then, during a non-blinded trial,switched from bimodal to Likert, 18 or more to qual-ify. To be classed as recovered, a bimodal score of ≤3out of 11, which represented a screening thresholdfor abnormal fatigue, and which equates to a Lik-ert score of 9 or less, was changed to a Likert scoreof 18 or less (0–33) . Consequently, with a Lik-ert score of 18, one was simultaneously classed asdisabled and recovered. Yet in a properly conductedtrial this should not happen. Nor should participantsbe selected for a trial who already fulfill one or moreof the recovery criteria at trial entry - before receivingany treatment.
These endpoint changes increased recovery ratesof CBT and GET 4-fold. Had the PACE trial stuck tothe protocol-defined endpoints, then there would havebeen no statistically significant difference in recoveryrates between the four treatment groups .
Consequently, the risk of selective reporting inWearden et al. (2010)  and White et al. (2011) was high, not only because some of the outcomeswere not reported or only reported many years later,but also because not all outcomes were reported inaccordance with their pre-defined protocols [28, 29].
2.4.2. Allegiance biasThe allegiance effect points to significant
researcher and clinician bias. Psychotherapeutictreatments and treatments based on presumed psy-chiatric aetiology have been reported to be especiallysusceptible to the allegiance effect . Part of theissue of allegiance bias in psychological therapies inparticular is that measures are often subjective, andthe clinician may unconsciously prod the subject torespond to their favoured therapy or not respond to atherapy they consider ineffective. For example, a ther-apist’s confidence in their therapy of choice is almostcertainly perceptible to the patient, even when this isnot overtly advertised .
The review itself and 7 of the 8 studies (Jasonet al., 2007, the exception ) were conducted by
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researchers with an allegiance to a particular modelof ME/CFS and to two interventions, CBT and GET,who wanted to prove their own theories. Generally, instudies examining more than one treatment approach,the treatment favoured by the researchers tends tooutperform other treatments [51–53]. Several factorsmay contribute to this effect, but one is likely to bethe manner in which the non-favoured, comparisontreatment is conceptualised and implemented. Often,when a treatment is used as a comparison condi-tion, it may be implemented in a weaker form thenwhen it is used clinically. Usually investigators maynot believe in the effectiveness of the control con-dition . Consequently, treatments might not bepresented to participants as equally likely to leadto improvement. This is especially important whenthe primary outcomes are self-report measures whichcan be strongly influenced by patients’ expectations.Finally, a researcher’s enthusiasm for a particulartreatment can also lead them to overinterpret theirfindings or overlook limitations .
Before they conducted their research, White (prin-cipal investigator of the PACE trial by Whiteet al. (2011)  and co-author in Fulcher andWhite (1997) ), Moss-Morris, Wearden, Powell,Chalder and Sharpe (co-authors of the PACE trial)were all known to have favoured the approach to theillness being tested. These investigators are strongproponents of the ‘unhelpful cognitions’ theory ofME/CFS, which they and other colleagues, had orig-inated and/or actively promoted. If their trials hadfailed to show significant improvement and recov-ery through GET, this would have undermined thevery theories of reversibility to which the investiga-tors have dedicated their careers. Consequently, therisk of latent bias was palpable from the outset . Itis notable that Jason et al. (2007) , the only studyconducted by a researcher without an allegiance tothe model, concluded that none of the four treatmentstrategies was “superior to another treatment strategyin all areas.”
2.5. Primary outcomes of the review
The primary outcomes of the review are fatigueand adverse effects. Larun et al. concluded that after12 to 26 weeks, exercise therapy probably reducesfatigue by 3.4 points on the Chalder fatigue scale(0 to 33) compared to no-treatment (usual care andwaiting-list) or relaxation and flexibility. They alsoconcluded that the effect on fatigue after 52 to 70weeks, is uncertain .
Larun et al. also conducted a sensitivity analy-sis to assess the impact, effect or influence of keyassumptions such as different definitions of out-comes, protocol deviations and missing data, on theoverall conclusions of a study . Their sensitivityanalysis showed that there was considerable hetero-geneity at the end of treatment which was caused bythe deviating results in Powell et al. (2001). Exclu-sion of that study from their analysis removed theheterogeneity but it also reduced the treatment effector standardised mean difference (SMD) of exercisetherapy according to Larun et al., from 0.66 to 0.44,which equates to the aforementioned 3.4 points and2.2 points on the Chalder fatigue scale, respectively.
Chalder Fatigue scores from the two studies (Pow-ell et al. (2001)  and Wearden et al. (2010) )that used the 11-point bimodal scale were re-scoredby the reviewers on the 33-point Likert scale. How-ever, as discussed earlier, when this was done byWearden et al. (2010) , a non-statistically sig-nificant difference was transformed into a clinicallymodest, but statistically significant effect [33, 34].It is a matter of concern, that changing one officialway of scoring an instrument to the other officialway can lead to a different outcome. Consequently,the Chalder fatigue scale should not be re-scored. Italso raises questions about its suitability as a primaryoutcome in the Cochrane review.
To help quantify the minimal important difference(MID) for fatigue, the Cochrane reviewers used astudy by Goligher et al. from 2008  among peoplewith systemic lupus erythematosus (SLE). Goligheret al. reported a threshold of around 2.3 points fora minimal clinically important difference (MCID)change on the 33-point Chalder Fatigue Scale, aneffect size that corresponds to an SMD of about 0.36.But other studies reported a higher MCID than thatchosen by Cochrane. For example, a study by Pou-chot - one of the authors of Goligher et al. - whichwas also from 2008, found that the MCID for fatiguein rheumatoid arthritis (RA) was 3.3. (Most personswith RA complain of fatigue). Pouchot was also partof the Ad Hoc Committee on SLE Response Criteriafor Fatigue . This committee concluded that theMCID should be a decrease of fatigue of 15%. Pou-chot and Liang, two of the authors of Goligher et al.,Pouchot et al. and the Ad Hoc Committee, were alsopart of the most recent study by Pettersson et al. that was set up to determine the MCID for seven mea-sures of fatigue in SLE. Pettersson et al. concludedin 2015 that the standardized MCID was 0.54, rep-
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resenting an improvement in fatigue of 4.4 on the33-point Chalder Fatigue Scale. Finally, a study byRidsdale et al. , into the efficacy of exercise ther-apy for people who presented with chronic fatiguein primary care, concluded that the mean differencebetween exercise and control group on the ChalderFatigue Scale should be 4 points.
The Cochrane review analysed the outcome of theChalder fatigue questionnaire, which was used byseven studies (Jason et al. (2007)  the exceptionas it used the fatigue severity scale or FSS). How-ever, contrary to the other studies, Fulcher and White(1997)  actually used two different fatigue scales.Unfortunately, the outcome on the VAS scale, whichshowed less improvement than the Chalder fatiguescale, was not analysed by the Cochrane review. After12 weeks of treatment (end of treatment), the Chalderfatigue score had improved by 18.7% (5.4/28.9) com-pared to the control group, yet the total fatigue scoreon the visual analogue scale (VAS) had only improvedby 6.4% (20/312). The VAS also highlighted the factthat the two groups in Fulcher and White (1997) werenot evenly matched for physical fatigue with scoresof 161 (GET) and 177 (flexibility control group).The scores for mental fatigue 151 (GET) and 148(flexibility) were evenly matched. The 10% differ-ence in physical fatigue scores is matched by a 11.3%(3.6/31.8) difference in oxygen consumption betweenthe two groups (31.8, GET and 28.2, flexibility).
There are also other problems with choosingfatigue, measured by the Chalder fatigue scale orquestionnaire, at the end of treatment as the pri-mary outcome. First of all, the protocol of Weardenet al. (2010) , better known as the FINE trial,noted that “Assessment at week 70 is requiredbecause short-term assessments of outcome in achronic health condition such as CFS/ME can bemisleading” . Secondly, there are many issueswith the Chalder fatigue scale (ChFS). The reanal-
yses of the Cochrane GET and CBT reviews listeda total of 10 different problems with it [5, 62].The following five are some of the most importantones:
• The ChFS does not provide a comprehensivereflection of fatigue related severity, symptomol-ogy or functional disability in ME/CFS;
• The ChFS suffers from the ceiling effect so that amaximum score at baseline cannot increase evenif there is deterioration during the trial;
• Few items on the ChFS clearly relate to fatigue;• The ChFS is unable to distinguish between
ME/CFS and primary depression;• Its scoring has limited evidence of test-retest
An important problem of the Chalder fatigue scaleis the above mentioned ceiling effect. This means thata maximum score at baseline cannot increase, even ifthere is deterioration during the trial. The releasedindividual participant data [63, 64] of both Wear-den et al. (2010)  and White et al. (2011) ,the only two trials of the eight that released thesedata, show that a large percentage of participants inboth trials had the maximum Chalder fatigue scoresat baseline as can be seen in Table 2. If these patientswith maximum scores at baseline, for example, hadimproved on three of the 11 items, and deterioratedon eight, then they should have been classified asdeteriorated by five points (eight minus three). But asthe eight scores could not get worse, these patientswould actually be classified as having improved bythree points.
Table 2 also includes the figures and percentagesfor some other scores, because for example with aLikert score of 30, patients had the maximum scoreon at least eight of the 11 questions. This means thateven if they did deteriorate on those eight questions,their scores could not reflect that.
Table 2Percentage of participants with (near) maximum Chalder fatigue scores at baseline
Study Bimodal 11 Bimodal 10 Bimodal 9 Total bimodal Likert 33 Likert 32 Likert 31 Likert 30 Total Likert9 – 11 30 – 33
Wearden et al.(2010) [17,63] (n = 196)
147 (75%) 19 (9.7%) 14 (7.1%) 180 (91.8%) 57 (29.1%) 17 (8.7%) 16 (8.2%) 18 (9.2%) 108 (55.1%)
White et al.(2011) [18,64] (n = 640)
417 (65.2%) 106 (16.6%) 57 (8.9%) 580 (90.6%) 93 (14.5%) 53 (8.3%) 58 (9.1%) 78 (12.2%) 282 (44.1%)
Number of participants (%); bimodal scoring: 0, 0, 1, 1 (0–11); Likert scoring: 0, 1, 2, 3 (0–33); Wearden et al. (2010)  released individualdata for the treatment group and the supportive listening group which they used for another study . Data for the no-treatment controlgroup was not released.
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Table 3Fatigue scores at the end of treatment compared to entry
Study Baseline End of Fatiguetreatment score entry
Wearden et al. (1998)  33.7 28.7 4 or moreWearden et al. (2010)  10.49 8.39 4 or moreWhite et al. (2011)  28.2 21.7 18 or more
Another problem of the Cochrane conclusionbased on the fatigue scores is highlighted in Table 3. Itshows that at the end of treatment, in the three studiesthat specified a minimum fatigue entry requirement,patients were still ill enough to re-enter that studyand receive the same treatment again. If a treatmentwould be truly effective, this would not be the case.
A minimum fatigue entry score was not specifiedin the other five studies - Fulcher and White (1997),Jason et al. (2007), Moss-Morris et al. (2005), Pow-ell et al. (2001) and Wallman et al. (2004) [11–15].Why they did not specify this is unclear, especiallyas fatigue was a primary outcome in most of them.
A 2003 study by Tench et al.  on the efficacyof exercise therapy for SLE further highlighted theproblems of the Chalder fatigue scale and the factthat it can lead to false-positive outcomes. This study,which included the principal investigator of White etal. (2011) , compared the efficacy of 12 weeks ofgraded exercise therapy with two other interventions(relaxation and no intervention). It used a number ofsubjective outcomes but also objective ones includ-ing VO2 peak. This study is of importance because itused three different measures for fatigue: the fatigueseverity score (FSS), the Chalder fatigue scale and thevisual analogue scale (VAS). The mean age in the trialwas 39, which is similar to the trials in the Cochranereview, and the groups were evenly matched. TheChalder fatigue scores after GET improved by 3points compared to relaxation and by 4 comparedto the no-treatment control group. This represents animprovement on the Chalder fatigue scale of 13.6%(3/22) and 18.2% (4/22) compared to relaxation andno-treatment, respectively. If Tench et al. had beenpart of the current Cochrane review, then the review-ers would have concluded that this study providedevidence of the efficacy of exercise therapy for SLEat the end of treatment. However, GET did not leadto improvement on the other two fatigue scales, nordid it lead to objective improvement. Also, improve-ments in Chalder fatigue scores were not maintainedat (three months) follow-up.
In conclusion, one cannot safely conclude that atreatment is effective if, after treatment, patients arestill ill enough to re-enter the same trial to receive thesame treatment again. Also, there are many problemsin using the Chalder fatigue scale in ME/CFS studies.In particular, the ceiling effect, in combination with ahigh percentage of patients with the maximum scoreat baseline, make this scale unreliable and thereforeunsuitable for use in ME/CFS studies.
2.6. Physical functioning
Larun et al. concluded that exercise therapy maymoderately improve physical functioning after 12to 24 weeks (low evidence) and the effect after 52to 70 weeks is uncertain (very low evidence) com-pared to no-treatment (usual care and waiting-list) orrelaxation and flexibility. They also stated that, whencompared to adaptive pacing, “the available evidencesuggests that exercise therapy may slightly improvephysical functioning” after 24 and 52 weeks (low evi-dence for both) . The reviewers noted that “Jason2007 observed better results among participants inthe relaxation group. The latter results were distortedby very large baseline differences in physical func-tioning between the exercise and relaxation groups(39/100 versus 54/100), and we therefore decidednot to include these results in the meta-analysis” .However, as discussed earlier, the objective physicalfunctioning scores of the 6MWT in Jason et al. (2007) are almost identical for both groups - 1335.27(exercise) versus 1317.78 (relaxation). Consequently,their results were not distorted because there were noobjective baseline differences in physical functioningbetween these two groups and Jason et al. should nothave been excluded from the meta-analysis.
The reviewers came to their conclusions aboutthe improvement of physical functioning based ona threshold for minimal important differences (MID)on the physical functioning subscale of the SF-36of around 7 points based on studies in people withrheumatoid arthritis or chronic heart disease . Min-imally important clinical differences (MCIDs) shouldbe estimated by an evaluation study similar in its pre-conditions to an investigative study that determineseffects. Ideally this should be done in the same dis-ease or a disease which is similar . Just like theCochrane reviewers, our review team could not finda study estimating the MCID in ME/CFS, or simi-lar illnesses like Multiple Sclerosis or fibromyalgia,for fatigue. However, such a study to determine theMCID for physical functioning for ME/CFS was done
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by Brigden et al. , albeit in children. They con-cluded in 2018 that the MCID was 10. In adults sucha study was not done in ME/CFS but in fibromyalgia,which is more similar to ME/CFS than rheuma-toid arthritis or chronic heart disease. It was doneby Kaleth et al. (n = 187)  and they concludedthat the MCID for the SF-36 physical functioning infibromyalgia (FM) is 10 and that this correspondswith a MCID for the six-minute walk test (6MWT)in patients with FM of 167 meters.
It makes a difference if a review uses a score of 7,as the reviewers did, or a score of 10. However, onan individual level, this does not make a differencebecause the SF36-PF consists of 20 questions andeach question counts for five points (0 to 100). So toimprove by 7, a respondent would need to improveon two questions, which equates to 10 points. Theonly study in the review to release individual partic-ipant data for the SF36-PF and the 6MWT is Whiteet al. (2011) [18, 64]. Table 4 shows the number andpercentage of participants in each of the groups ofthat study who improved by 10 or more points onthe SF36-PF. The data also shows that in each grouponly a small percentage of them improved by 167 mor more on the 6MWT. Moreover, GET (8.0%) wasnot more effective than no-treatment (8.3%) and CBT(3.9%) was the least effective of the four. It is alsoknown that there is an inverse relationship betweenfatigue and physical functioning/activity . Thissuggests that the small subjective improvement offatigue after GET over no-treatment, was simply anartefact. At the same time, the analysis of the individ-ual PACE trial data , shows that in 20% of cases,patients improved subjectively even though they dete-riorated objectively, as can be seen in Table 4. Thistable also shows that in a considerable number ofcases, for those whose subjective physical function-ing scores had improved by 10 or more, the 6MWT
scores were missing. This means that we actually donot know if these patients improved or deterioratedaccording to objective measures.
In conclusion, an increase in subjective physicalfunctioning with an objective decrease in physicalfunctioning in a considerable number of cases, high-lights the unreliability of subjective outcomes.
2.7. Quality of life
According to the Cochrane review , quality oflife was only measured in Jason et al. (2007) ,“which observed an MD [mean difference] of 9.00.The estimate is biased in favour of the control armbecause of baseline differences between groups.”By this, the reviewers meant the baseline differencein subjective physical functioning scores betweenanaerobic activity therapy (ACT) and the relax-ation control group (RELAX). However, as discussedearlier, the objective physical functioning scores (6-minute walk test) of the groups, were almost identical.Consequently, there were no baseline differences inphysical functioning. Improvement in quality of lifescores was 3.5% (ACT) and 12.3% (RELAX) and inthe 6-minute walk test this was 3.2% (ACT) and 8.4%(RELAX). The quality of life scores, on the Qualityof Life Scale (QOLS), at the twelve-month follow-upwere 63.0 (ACT) and 72.0 (RELAX) (QOLS range:16 to 112; higher scores indicating higher quality-of-life). These QOLS scores were still worse thanfor people with fibromyalgia (70), COPD, psoriasisand urinary incontinence (82), rheumatoid arthritis(83), systemic lupus erythematosus (84), osteoarthri-tis (87) and young adults with juvenile rheumatoidarthritis (92) .
Contrary to Cochrane’s findings, quality of life wasnot only measured in Jason et al. (2007) , but alsoin the PACE trial by White et al. (2011), who pub-
Table 4Improvement in subjective and objective physical functioning in the PACE trial according to the released individual participant data
Outcome measure CBT (n = 161) APT (n = 159) SMC (n = 160) GET (n = 160) Total
SF-36 PF improvement ≥10 103 (64.0%) 71 (44.7%) 84 (52.5%) 112 (70%) 370 (57.8%)Combined improvement of SF-36
PF ≥10 + 6MWT ≥167 m4 (2.5%) 4 (2.5%) 7 (4.5%) 9 (5.5%) 24 (6.5%)
SF-36 improved ≥10 yet 6MWTworsened
21 (20.4%) 11 (15.5%) 14 (16.7%) 16 (14.3%) 62 (16.8%)
Missing 6MWT data of thosewhose SF-36 PF improved ≥10
16 (15.5%) 16 (22.5%) 17 (20.2%) 25 (22.3%) 74 (20%)
SF-36 improved ≥10 yet 6MWTworsened for those with6MWT data
24.1% (21/87) 20% (11/55) 20% (14/70) 16.7% (16/96) 20.1% (62/308)
6MWT: Six minute walk test; PACE trial: White et al. (2011) ; SF-36 PF: Short Form 36 Physical Functioning Health SurveyQuestionnaire; White et al. released individual participant data .
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Table 5Quality of life scores and QALYs in the PACE trial
Time point APT GET SMC (no-treatment)
Missing data (%) 11/159 (6.9%) 17/160 (10.6%) 9/160 (5.6%)Baseline score 0.48 0.52 0.5024 weeks (EOT) 0.54 0.60 0.5252 weeks follow-up 0.54 0.59 0.53QALYs accrued 0.53 0.57 0.52Net improvement after GET from control at 24 wks (%) 0.02 (3.8%) – 0.06 (11.5%)Net improvement after GET from control at 52 wks (%) 0.01 (1.9%) – 0.04 (8.4%)Net improvement in QALYs accrued 0.05 (10.4%) 0.05 (9.6%) 0.02 (4%)
EOT: end of treatment; FU: follow-up; QALYs: according to White et al. (2011) , quality adjusted life years were generated from theEQ -5D health-related quality of life questionnaire; wks: weeks. Quality of life scores from the PACE trial  were published in their costeffectiveness analysis .
lished this in their cost effectiveness analysis .This analysis was published one year after their orig-inal publication  and it was one of the referencesto studies included in the Cochrane review .
The net improvement of the quality of life scores(EQ-5D) after GET at 52 weeks over the adaptivepacing control group in the PACE trial, was 1.9%.A study by Olesen et al.  (n = 20,220) found amean quality of life score of 0.84 for the total popula-tion and 0.93 for people without a chronic condition.Yet, the quality of life at 52 weeks in the GET group(0.59)  was similar to the score (0.60) for peo-ple with five or more chronic health conditions andworse than in cerebral thrombosis (0.62), rheumatoidarthritis and angina (0.65), acute myocardial infarc-tion (0.66) , MS (0.67), lung cancer (0.69), stroke(0.71) or ischemic heart disease (0.72) (linear scaleranging from –0.624 to 1.000 where negative valuesare conditions considered worse than death; higherscores indicating a better quality of life) .
Finally, the net improvement in QALYs (quality-adjusted life-year) - which refers to gains in health,combining a time dimension and an adjustment forquality of life  - was marginally better after pac-ing than after GET. In conclusion, one cannot safelyconclude that GET is an effective treatment in view ofthe lack of significant improvement of quality of lifescores after exercise treatment in Jason et al. (2007)and White et al. (2011). In fact, even after treatment,the quality of life scores remain lower than in manyother disabling diseases.
2.8. Objective outcomes
The objective outcomes were not discussed by theCochrane review, even though they were used byseven of the eight studies. Powell et al. (2001), thestudy that was removed by the Cochrane review after
their sensitivity analysis, was the only study not touse them. As can be seen in Table 6, in most studies,exercise therapy did not lead to objective improve-ment. In Fulcher and White (1997) , there was asmall improvement at the end of treatment, yet thecontrol group was badly matched and patients in theexercise group had normal fitness at baseline. More-over, participants in the exercise group had sessionsof five to fifteen minutes, increasing to a maximum ofthirty minutes, at least five days a week. Such a work-load would exclude most patients with ME/CFS. InWearden et al. (1998) , the groups were badlymatched as well and in Wallman et al. (2004) ,pacing was labelled as GET and pacing, as discussedearlier.
In conclusion, the objective outcomes used byalmost all the studies in the Cochrane review showthat GET does not lead to clinically significant objec-tive improvement.
2.9. Chronic Fatigue Syndrome symptom count
This was measured by White et al. (2011) .Figures for end of treatment were not released, butat 52 weeks there was no statistically significantdifference in the improvement in Chronic FatigueSyndrome symptom count between GET and SMC(p = 0.0916) or GET and APT (p = 0.23).
2.10. Did patients comply with graded exercisetherapy?
The only trial that answered this question is Wear-den et al. (1998) . In this study, 67 patientswere randomised to graded exercise and fluoxetineor to graded exercise and drug placebo. Of these67 patients, only 34.3% (23/67) complied fully withgraded exercise. In the exercise placebo groups,
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Table 6Objective improvements after exercise therapy compared to control
Study Rx Control Objective Baseline Obj improvement Obj improvementoutcome compared to control
(EOT)compared tocontrol (FU)
Fulcher andWhite(1997) (n = 66);
GET Flex + relax VO2 peak 31.8 7.5% (2.4/31.8; 12wks)
Jason et al.(2007) (n = 114)
ACT Relax 6MWT 1335.27 –– Relax improved 5.1%(68.42/1335.27)more than ACT
Moss–Morriset al. (2005) (n = 49)
GET NT VO2 peak 31.99 Both groupsdeteriorated; by14.9% (4.78/31.9)exercise and 16.8%(5.22/31.0) NT;difference notstatisticallysignificant p = 0.39)
Powell et al.(2001) (n = 148)
GET NT –– –– –– ––
Wallman et al.(2004) (n = 61)
Pacing Relax + flex O2 uptake 15.6 9% improvement +flexibility worsenedby 8%
Wearden et al.(1998) (n = 136)
Exercisecontrol (NT)+ placebodrug
19.9 10% (26 wks) ––
Wearden et al.(2010 and2013) [17,33] (n = 296)
GIA NT ST Not published “No between groupdifferences” (p = 0.819; 20 wks)
“No between groupdifferences”(p = 0.832; 70 wks)
White et al.(2011) (n = 640)
GET APT and NT 6MWT; Steptest;Actometer
312 6MWT;Step test:figures notpublished;usingActometerat FUcancelled
–– 6MWT: 41.0 APT;35.3 NT; Step test:GET had no effecton fitness; exactmean scores notpublished 
6MWT: six-minute walk test; APT: adaptive pacing treatment; EOT: end of treatment; FU: follow-up; GIA: gradually increasing activity;NT: no-treatment; O2: oxygen; Rx: treatment; wks: weeks. In Wallman et al. (2004) , pacing was labelled as GET and pacing (seeproblems with the controls). Also, they used a submaximal cycle test to measure oxygen uptake.
patients “were not offered any specific advice on howmuch exercise they should be taking, but were toldto do what they could when they felt capable andto rest when they felt they needed to.” 78.3% (54 ofthe 69 patients) in the two control groups, who weretreated with exercise placebo and fluoxetine or exer-cise placebo and drug placebo, complied fully withexercise placebo.
In conclusion, only one trial measured if patientscomplied with exercise therapy. They found that onlyone out of three participants treated with exercisetherapy, actually complied with it. Consequently, onecannot safely conclude that exercise therapy is effec-
tive in that study. As far as the other studies areconcerned, if one does not know if patients actuallyadhered to the prescribed exercise regime, then onecannot conclude if that treatment is safe or effective.
2.11. A study was excluded that contradicted themain findings
Núñez et al. (2011) , was excluded fromthe Cochrane review, because, according to thereviewers, exercise therapy was a minor part of theintervention and it did not measure outcomes viewedas primary outcomes in the review .
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The trial compared multidisciplinary treatmentcombining CBT, GET and pharmacological treat-ment with usual treatment. It found that at twelvemonths follow-up, the interventions did not improvehealth-related quality of life scores, and led to worsephysical function and bodily pain scores. Núñez et al.concluded that “the results of our study tend to sup-port the somewhat controversial findings of Twiskand Maes that the combination of CBT and GET isineffective and not evidence-based and may in factbe harmful” .
3. Work rehabilitation and medicalretirement in ME/CFS
3.1. Presenting to an occupational healthphysician
According to a recent review of work rehabilita-tion and medical retirement in ME/CFS , mostpatients who present to their occupational healthphysician with chronic fatigue (CF) do not sufferfrom ME/CFS, The single most important factor indiscriminating ME/CFS from idiopathic CF or psy-chiatrically explained CF, is postexertional malaise(PEM), the main characteristic of ME/CFS. PEMis also an important prognostic indicator of pooreroutcome at follow-up .
Routine testing does not reveal any abnormali-ties in most patients with ME/CFS. Consequently,large parts of the medical profession view ME/CFSas a psychological disorder. However, increasinglyadvanced tests have become available over the last5–10 years, and as noted by Komaroff in a recentoverview , more and more studies are document-ing underlying biological abnormalities, involvingmany organ systems, in patients with ME/CFS. Theseabnormalities include metabolic changes, lactic acidproduction irregularities, immunological abnormal-ities in lymphocytes - especially in T cells andpoorly functioning natural killer cells - and signif-icant elevation of many blood cytokines, especiallyin the first three years of illness, which are corre-lated with the severity of the illness. These studieshave also shown widespread neuro-inflammation ofthe brain and cognitive impairments, not explainedby concomitant psychiatric disorders. Multiple car-diopulmonary exercise test (CPET) studies havedemonstrated an impairment in the cellular energyproduction in patients with ME/CFS. This energyproduction impairment is much more prominent dur-
ing a second exercise test repeated 24 hours after thefirst . A study by Melamed et al. that used invasiveCPET - so that arterial blood samples could be takenrepeatedly during the test - concluded that “exertionalintolerance is caused solely by poor systemic oxygenextraction.” Abnormal peripheral oxygen extraction“is also the exercise hallmark of the mitochondrialmyopathies” for example .
3.2. ME/CFS problems interfering with work
ME/CFS is far from a rare disease . In theNetherlands, for example, it is more common thanMS . Diagnosing can be difficult and up to 90%of patients remain undiagnosed . This occursbecause, on the one hand, most doctors do not knowmuch about the disease and on the other hand becausethere is no diagnostic test. Treatment is based onsymptom management. The most important prob-lems interfering with work, according to research byTNO , an independent Dutch research institute,are muscle pain, severe and disabling chronic fatigue,cognitive dysfunction - concentration or short-termmemory impairments, difficulty with reading orinformation processing. The other really importantproblem interfering with work is PEM . To beconsidered disabled in the US, patients have to beable “to do sustained work activities in an ordinarywork setting on a regular and continuing basis...A“regular and continuing basis” means [being able towork] 8 hours a day, for 5 days a week” . PEMkeeps them from being able to do that.
Other symptoms which occur in more than 80% ofcases, according to a large nationwide population-based cohort study by Castro-Marrero et al. ,are muscle weakness, dizziness, generalized chronicpain and/or joint pains, hypersensitivity to noiseand/or light, new onset headaches or migraines, andepisodes of postural orthostatic hypotension (POTS).Characteristic of the disease is that symptoms andimpairments increase following exertion. But theycan fluctuate in nature and severity throughout thecourse of the disease and they can differ from patientto patient.
ME/CFS can interfere with the ability to show upat work every day and/or stay all day long and withwork-related physical functions like walking, sitting,standing, lifting, carrying, pushing, pulling, reach-ing, and handling. It can also interfere with cognitivefunctions including the ability to remember, under-stand, and carry out simple instructions, the ability touse appropriate judgment, and the ability to respond
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appropriately to supervision, co-workers, and usualwork situations, including changes in a routine worksetting .
3.3. Prognostic factors
The most important prognostic factor is how theillness is managed in its initial stages, according to Dr.Melvin Ramsay . He was the infectious diseasespecialist who was involved in the management of thealmost 300 patients, mainly doctors and nurses, whofell ill during the outbreak in the Royal Free Hospitalin London in 1955. He also noted that most patientswill try to go back to work in the initial stages whenthey are improving. With many other illnesses, thatdoes not pose a problem but with ME/CFS it does. Asdocumented by Dr Ramsay, “those patients who aregiven a period of enforced rest from the onset havethe best prognosis” .
Other factors associated with a worse outcome areillness duration and severity, older age, or having acomorbid psychiatric disorder when patients fall ill.
3.4. Work rehabilitation
According to the report by the IOM, “ME/CFSsymptoms often are so debilitating” that “35 to 69percent” are unable to work as found by a review of15 studies . For the minority who have improvedenough and whose own work, or adapted work, isphysically light enough to consider a return to work,work rehabilitation will usually need to start with adramatically reduced workload and number of hours[88, 89]. For these patients, an individualised return towork plan should be developed, taking the symptomsand specifics of the disease and the way it is affectingthe individual employee into account. In particular,care should be taken to match the subject’s capabili-ties to the proposed employment duties with the needfor flexibility to adjust time of day to start work, theability to work from home, etc. Work that is likelyto place sustained high pressure on the employeelike strenuous physical work, long working hours,work requiring sustained high levels of attention andconcentration or rapidly changing shift patterns, isinadvisable or at the very least, requires careful mon-itoring until it is clear that the employee is able tosustain this level of work. Definite deadlines in antic-ipating recovery and future employability should notbe set to avoid causing relapses .
3.5. Disability Discrimination Act
In the UK, most employees with ME/CFS usedto fall under the Disability Discrimination Act 1995, which was replaced by the Equality Act 2010in England, Scotland and Wales but not in NorthernIreland . The Equality Act covers the provisionsin the Disability Discrimination Act. It also offersadditional protection from indirect discrimination,discrimination arising from disability and discrim-ination on the basis of association or perception.Disability is defined as “a physical or mental impair-ment” which “has a substantial and long-term adverseeffect on a person’s ability to carry out normal day-to-day activities” .
According to this Act, employers are required tomake ‘reasonable adjustments’ to the workplace andto working practices, so that a disabled or chroni-cally ill employee is not at a disadvantage, comparedto healthy and able-bodied employees, and is able towork despite his or her disability. Workplace adjust-ments that fall under this disability act could include:changing work and/or location of work, limitingworking hours, reducing workload, working fromhome, and limiting or reducing physical tasks [88, 89,91]. Most other western countries will likely have asimilar Act in place to protect disabled workers.
3.6. Important factors enabling a return to work
According to a report by NIVEL, the NetherlandsInstitute for Health Services Research , thereare a number of important things which enabledME/CFS patients to (return to) work. For 92%, themost important thing was support in finding the rightbalance between work and spare time. The secondmost important thing (84%), was support and cooper-ation from the employer to enable patients to continueto work. Other important things were the following:
• supplying information about ME/CFS to col-leagues and superiors (62%);
• changing tasks (61%);• reducing the number of hours they had to work
(61%);• more rest periods during working times (60%);• the availability of a special rest place at work
(45%);• working from home (52%);• individual support and coaching in general
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• and by an occupational health physician in par-ticular (44%);
• adjustments to working conditions (furniture,physical aids) (38%);
• and a regulation or provision for commuting towork (36%).
3.7. Medical retirement
Many patients with ME/CFS are too disabledto work and as a consequence are receiving longterm disability benefits. In cases when incapacityis prolonged, work rehabilitation is impossible orunsuccessful, and prognosis appears to be poor, thenmedical retirement is often the only option. The occu-pational health physician/doctor may then be askedto advise on this. Qualifying criteria of a companypension scheme inevitably vary, although permanentinability to undertake normal duties for reasons ofill health is a common requirement in the UK [88,89, 91]. In contrast, patients in the Netherlands canbe granted full or partial temporary medical retire-ment, without the need to prove permanent inability. Nyland et al. did a long-term follow-up studyof seven years in young adults (n = 111) who haddeveloped ME/CFS after glandular fever / mononu-cleosis and had been ill for a mean of 4.7 years atthe start of the study. Their study showed that inyounger patients, who have a much better prognosisthan older patients in general and even more so afterglandular fever, “long-term compensations to securethe socioeconomic position does not inhibit return towork, but may be essential contributors to...becomingemployed” later on .
At the beginning of October 2019, Cochrane pub-lished a long-awaited amendment to its review ofexercise therapy for ME/CFS  following a formalcomplaint to its Editor in Chief . In this article weanalysed the amended version. We also summarisedthe recently published review of work rehabilitationand medical retirement in ME/CFS  as they anal-ysed a large number of studies, which reported onwork outcomes in trials of CBT and GET, includingthose in this Cochrane review. Unfortunately, the pub-lished amendment does not address the main flaws ofthe Cochrane review and the studies in it, continuesto overestimate the evidence for exercise therapy inME/CFS and downplays the flaws of those studies.
The main conclusions of the Cochrane reviewerswere the following:
1 “Exercise therapy probably has a positive effecton fatigue [at the end of treatment] in adults withCFS compared to usual care or passive thera-pies’’;
2 “The evidence regarding adverse effects isuncertain’’;
3 “All studies were conducted with outpatientsdiagnosed with 1994 criteria of the Centers forDisease Control and Prevention or the Oxfordcriteria, or both. Patients diagnosed using othercriteria may experience different effects’’;
4 Limited evidence makes it difficult to drawconclusions about the effectiveness of exercisetherapy compared to adaptive pacing or otherinterventions.
However, the main characteristic of ME/CFS isan exacerbation of some or all of an individual’sME/CFS symptoms that occurs after physical or cog-nitive exertion and leads to a reduction in functionalability - also known as postexertional malaise (PEM). This core symptom is not required according tothe Oxford criteria  and only optional accordingto the Fukuda criteria . “Using the Oxford casedefinition results in a high risk of including patientswho may have an alternate fatiguing illness or whoseillness resolves spontaneously with time,” accordingto the American Agency for Healthcare Researchand Quality (AHRQ) . Both AHRQ and theAmerican National Institute of Health (NIH) [23,24], recommended that the flawed Oxford criteriashould be retired.
4.1. Bias and flaws
Unfortunately, serious issues with the selection cri-teria were not the only flaws of the studies in thereview and the review itself. Another important issueis the fact that all studies in the review were non-blinded by definition and they were using subjectiveprimary outcomes. The reviewers acknowledge thatrelying on subjective primary outcomes in such trialsincreases the risk of performance and detection biasbut they do not think that is a problem because “manygroups representing the interests of those with CFSare opposed to exercise therapy, and this may in con-trast reduce the outcome estimate” . However, ifthat would be the case, then the majority of patientswould not take part in those studies and only thosewho are only very mildly affected and do not have a
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major problem with exercising would take part. Con-sequently, the self-selection of participants wouldreduce the generalisability of the results dramaticallyand increase instead of reduce the bias. Moreover, thefollowing figures from the PACE trial, one of the eighttrials in the Cochrane review, contradict the statementfrom the reviewers. At baseline and before treatmentwas started, the PACE trial researchers asked the par-ticipants if treatment is logical and 84% (APT), 71%(CBT), 84% (GET) and 49% (SMC) answered yes tothat question .
The four Cochrane reviewers, just like the investi-gators of seven of the eight trials in their review, aresupporters of the biopsychosocial model. This modelis based on the assumption that there is no underly-ing illness in ME/CFS. Instead, patients are deemedto have false illness or dysfunctional beliefs thatexercise is bad for them, and patients subsequentlydevelop fear of exercise and become deconditioned.According to this model, deconditioning is the reasonfor the symptoms of ME/CFS. However, it is illogi-cal to then determine if exercise therapy is effectiveby using subjective outcomes in patients who don’tknow how to interpret their symptoms correctly. Theonly way to adequately check if fitness has improvedand patients are not deconditioned anymore, is byusing objective fitness outcomes. Yet, none of theeight studies in the Cochrane review used objec-tive outcomes as primary outcomes. The Cochranereview itself, left out an analysis of the objectiveoutcomes which were used as secondary outcomesby seven of the eight studies in the review. A sim-ple, cheap, reliable and easy objective outcome touse is the six-minute walk test , which was usedby two of the eight studies. There was no clinicallysignificant objective improvement according to thesix-minute walk test in the PACE trial (White et al.(2011) ) and in Jason et al. (2007) , wherepatients objectively improved more with relaxationthan with exercise.
A systematic review by Hróbjartsson et al. ,concluded that there is pronounced bias due to lackof patient blinding in clinical trials with patient-reported outcomes and that non-blinded patientsexaggerated the effect size by an average of 0.56 stan-dard deviation. According to the Cochrane review,at the end of treatment when compared to no-treatment, the effect size was 0.66. They alsoconcluded that one of the studies in the review didnot pass their sensitivity analysis and after exclud-ing that study, the effect size dropped to 0.44. Thisis less than the effect size of relying on subjec-
tive outcomes in non-blinded studies as found byHróbjartsson et al.
The BRANDO project (Bias in Randomised andObservational studies) , which amongst othersincluded Stanford professor Ioannidis, concluded in2012 that “as far as possible, clinical and policy deci-sions should not be based on trials in which blindingis not feasible and outcome measures are subjectivelyassessed” because lack of blinding is “associatedwith an average 13% exaggeration of interventioneffects”. “Therefore, trials in which blinding is notfeasible should focus as far as possible on objectivelymeasured outcomes.” The Cochrane review and thestudies in it, failed to do this.
4.2. Methods that help to show that treatment iseffective, even when it is not
Cuijpers and Cristea  concluded that thereare several methods available to help researchersshow that their therapy is effective, even when it isnot. According to them, these methods “include astrong allegiance towards the therapy, anything thatincreases expectations and hope in participants, mak-ing use of the weak spots of randomised trials (riskof bias), small sample sizes and waiting list con-trol groups” or no-treatment groups. Many of thesemethods were seen in the studies in the Larun review.
First, researchers of seven of the eight trials in thereview had a strong allegiance towards the therapy.According to a systematic review by Dragioti et al.,“experimenter’s allegiance effect inflates the reportedeffect sizes in randomized controlled trials in psy-chotherapy by 30 %” . Jason et al. (2007) , theone study where this was not the case, “found few dif-ferential results among the [four] non-pharmacologicinterventions.”
Second, during the PACE trial - the largest CBTand GET trial ever conducted - patients were senta newsletter which stressed that in the new NICEguidelines, “recommended therapies include Cogni-tive Behavioural Therapy, Graded Exercise Therapyand Activity Management” .
Further, a key feature of GET is pushing beyondlimits. In the PACE trial’s GET manual for partici-pants, participants are told to interpret symptom flaresas “a normal part of CFS/ME recovery” and not as aworsening of the disease . In the FINE trial patientbooklet, patients are told that “Activity or exercisecannot harm you” and that “medical research evi-dence shows: no underlying serious disease.” “Youwill have conquered CFS by your own effort and you
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will be back in control of your body again.” Thatbooklet also states that “you cannot relapse becauseyou now know how to combat it” .
Third, five of the studies in the review usedno-treatment control groups, which were labelledtreatment as usual care, specialist medical care, exer-cise placebo etcetera. The Cochrane review itselfrelied on exercise compared to the no-treatment con-trol group at the end of treatment to label exercisetherapy moderately effective for fatigue in ME/CFS.
Fourth, the reviewers introduced further bias intotheir review in two other ways. First of all by pub-lishing it in the Cochrane Common Mental DisordersGroup and giving the wrong impression about ME,which has been classified as a neurological diseasesince 1969 by the World Health Organisation withCFS as an equivalent . Secondly, according tothe acknowledgement section of their review, theCochrane reviewers asked two proponents of thebiopsychosocial model, who inappropriately viewME/CFS as a behavioural problem and CBT andGET as effective treatments, for advice on an exer-cise review. This introduced further bias into theirreview as one of them is not only a psychiatrist, butalso a co-author of Fulcher and White (1997) and the principal investigator of White et al. (2011), two of the studies in the review. This is akin toasking students for advice on how to mark their ownexam papers. If the reviewers thought it was neces-sary to ask for advice for their exercise review, thenit would seem more logical and appropriate to askfor advice from exercise physiologists. For example,Professor Keller, or Professors Davenport, VanNessand Snell who have published many exercise phys-iological papers on ME/CFS [101–106] yet had noinvolvement with the studies in the review. Maybethe reason why they were not asked for advice is thatin May 2018, VanNess et al. concluded that “gradedexercise aimed at training the aerobic energy system,not only fails to improve function, but is detrimentalto the health of [ME/CFS] patients and should not berecommended” .
4.3. Problems with the primary outcomemeasure
Fatigue was used as the main primary outcome ofthe review - the other one was safety of exercise ther-apy - and seven of the eight studies used the Chalderfatigue scale. As discussed earlier, there are manyproblems with this instrument. One of the problems isthe ceiling effect whereby scores of patients who have
the maximum score at baseline - or have the maxi-mum score for individual items - cannot get worse(on these items) if they deteriorate. The consequenceof this can be for example that if patients deteriorateon eight items and improve on three, that their scoresreflect an improvement by three even though in real-ity they have deteriorated by five. The magnitude ofthis problem was highlighted by the individual partic-ipant data of the FINE trial and PACE trial [63, 64], ascan be seen in Table 2. This shows for example, that75% of participants in the FINE trial - Wearden et al.(2010)  - for whom individual data was released,had the maximum Chalder fatigue score at baseline.
Wallman et al.  analysed the reliability of theoutcome variables in their own study (Wallman et al.(2004) ), which was part of the Cochrane review.They concluded that the mental and physical Chalderfatigue scores at baseline “were of questionable relia-bility in both groups” and of moderate reliability aftertreatment. Yet the “post-intervention scores for peakoxygen uptake...and peak power (W·kg-1) were allsimilar to baseline values (i.e. highly reliable)”.
The Cochrane review analysed the Chalder fatiguescale (ChFS) outcome in Fulcher and White (1997). They did not analyse the outcome of the secondfatigue questionnaire - visual analogue scale (VAS) -used by the same trial. Improvements in fatigue com-pared to the control group were the following: 18.6%(ChFS) yet only 6.4 % (VAS). The VAS also high-lighted the fact that the two groups were not evenlymatched for physical fatigue. A study into the effi-cacy of exercise therapy for SLE, in patients withoutactive disease, highlighted the problems of relyingon the Chalder fatigue scale . At the end of treat-ment, the ChFS scores after GET had improved by 3points compared to relaxation and by 4 compared tothe no-treatment control group which is similar to thetreatment effect on fatigue of 3.4 after exercise in theME/CFS studies according to the Cochrane exercisereview. However, GET did not lead to improvementon the other two fatigue scales - FSS and VAS - nordid it lead to objective improvement in the SLE study.Also, at three months follow-up the improvement onthe ChFS had disappeared.
It is also unclear why the review relied on an out-come at the end of treatment, as a systematic reviewby Whiting et al. concluded in 2001 that because ofthe relapsing nature of ME/CFS, “follow-up shouldcontinue for at least an additional 6 to 12 months afterthe intervention period has ended, to confirm that anyimprovement observed was due to the interventionitself and not just to a naturally occurring fluctua-
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tion in the course of the illness” . And a studythat was part of the Cochrane review - Wearden et al.(2010)  - noted in their protocol that “short-termassessments of outcome in a chronic health conditionsuch as CFS/ME can be misleading” . Therefore,their primary outcome was at 70 weeks and not atthe end of treatment and the Cochrane review shouldhave done the same thing.
Whiting et al. also concluded that subjective out-comes may be unreliable because “persons may feelbetter able to cope with daily activities because theyhave reduced their expectations of what they shouldachieve, rather than because they have made anyrecovery as a result of the intervention. A more objec-tive measure of the effect of any intervention wouldbe whether participants have increased their workinghours, returned to work...or increased their phys-ical activities” . Moreover, unlike self-reportmethods, objective measures are less susceptible tosubjectivity and tend to yield more accurate resultsregarding fitness and reconditioning , not onlyin ill patients but also in the healthy population .The unreliability of subjective outcomes is high-lighted by the following examples from three trialsthat were part of the Cochrane review:
1. In Jason et al. (2007) , there was a substan-tial difference in subjective physical functioningscores at baseline between exercise and controlgroup, yet objectively there wasn’t (6MWT);
2. In Moss-Morris et al. (2005) , after GET,physical functioning subjectively improved by30%, yet objectively deteriorated by 15%(CPET);
3. In the PACE trial by White et al. , physicalfunctioning improved subjectively yet deteri-orated objectively (6MWT) in a considerablenumber of participants, as can be seen in Table 4.
4.4. Core set of outcome measures in exercisetrials
A Cochrane review into the efficacy of exercisetherapy for multiple sclerosis (MS) - a disease withmany similarities with ME/CFS - concluded in 2005that there is an urgent need for a consensus on a coreset of measurements of outcome to be used in exercisetrials. These outcome measures should be reliable andvalid and reflect activities of daily living and qualityof life domains. In addition, these studies should bemethodologically sound and also use objective out-comes . A systemic review by Latimer-Cheunget al.  into the efficacy of exercise therapy for
MS implemented this urgent need for a core set in2013 by using indicators of physical capacity thatincluded aerobic capacity, measured via CPET, mostcommonly defined as maximal oxygen consumption(VO2 max), and anaerobic threshold as these fitnessoutcomes are relevant to mobility, performance ofactivities of daily living, fatigue, and quality of lifeamong individuals with MS according to the authors.This review did not focus on one outcome (fatigue)as was done by Larun et al., even though fatigue isoften an important problem in MS.
Walking impairment is one of the most commonand life-altering features in MS, just like it is inME/CFS. Walking impairment is most commonlyassessed with performance measures such as the 6-minute walk test. This test was used by Jason et al.(2007)  and White et al. (2011) , and justlike the other objective outcome measures used bythe trials in the review, showed that graded exercisetherapy does not lead to clinically significant objec-tive improvement. This was found by the reanalysisof the Cochrane exercise review  and can also beseen in Table 6.
The Cochrane review also concluded that “The evi-dence regarding adverse effects is uncertain” becauseonly two of the eight studies reported on the safetyof the intervention. Consequently, the review pro-vided no evidence that exercise therapy is actuallysafe. Safety of patients should always come first. Ifa study cannot guarantee safety, then that treatmentshould not be recommended. This is particularly sowhen patient surveys over the last 20 years haverepeatedly shown that exercise therapy is harmfulin at least 50% of cases, as was found by Kindlon and Geraghty et al.  who pooled surveysin 2011 and 2017, respectively. Moreover, in the UK,the National Institute for Health and Clinical Excel-lence (NICE) is reviewing their ME/CFS guideline.A survey amongst ME/CFS patients (n = 2,274) car-ried out for the NICE review process by the OxfordBrookes University , dated the 27th of February2019, found the following. 98.5% of the patients whotook part in the survey experienced post-exertionalmalaise, the core symptom of the disease.
Worsening of symptoms after treatment wasreported by:
• 81.1% (GET);• 85.9% (GET combined with CBT);
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• 58.3% (CBT combined with GET).After treatment, the percentage of severely affected
patients increased from:
• 12.9% to 35.3% (GET);• 13.2% to 41.9% (GET combined with CBT);• 12.6% to 26.6% (CBT combined with GET).Black and McCully  concluded in 2005 “that
CFS patients may develop exercise intolerance...after4–10 days. The inability to sustain target activ-ity levels, associated with pronounced worsening ofsymptomology, suggests the subjects with CFS hadreached their activity limit.” A recent study by Lienet al.  concluded again that exercise deterioratesphysical performance and increases lactate in patientswith ME/CFS, whereas in the healthy population theexact opposite happens.
Also, as found by the PACE trial , exercisedoes not improve ME/CFS symptom count. The netimprovement in QALYs (quality-adjusted life-year),in the PACE trial was marginally better after pacingthan after GET and quality of life was still worse thanin lung cancer, acute myocardial infarction, MS andother debilitating illnesses. And in Jason et al. (2007), quality of life improved more after relaxationthan after exercise therapy.
Finally, a study can only report that a treatmentis safe or effective, if one knows if the participantshave actually adhered to the treatment. Only one trial- Wearden et al. (1998)  - answered this question.34.3% complied fully with exercise treatment versus78.3% with no-treatment. As concluded by Lilienfeldet al., participants who do not respond to treatment orare negatively affected by it, are more likely to dropout or be lost to follow-up . In other words, twoout of every three patients in the exercise group inWearden et al. (1998) did not comply with the exer-cise regimen. Most likely this happened because theyhad no benefits from the treatment or were adverselyaffected by it. In the other seven trials, it is unclearif participants actually adhered to the treatment ornot. In view of this, one cannot safely conclude that atreatment, in this case exercise treatment, is effective.
4.6. ME/CFS and prognosis
ME/CFS is a debilitating multisystem disease .Most cases tend to start as an unremarkable viralinfection. However, instead of recovering, patientsbegin to experience profound muscular (and cogni-tive) fatigue - for example heavy legs - following
activities which were previously completed withoutdifficulty. Also typical is an abnormally prolongeddelay in the restoration of muscle (and brain) power. Prior to developing ME/CFS, most patientswere sporty, healthy, and active . There is nodiagnostic test, therefore diagnostic criteria are usedto diagnose ME/CFS. Illness severity can differ frompatient to patient, but also throughout the course of thedisease. Most people believe that fatigue is the maincharacteristic. However, as concluded by the Insti-tute of Medicine in 2015, the main characteristic ispostexertional malaise (PEM), which is an increasein symptoms after physical or mental exertion andfurther loss of functioning . This core symptomdistinguishes ME/CFS from psychiatric fatigue andfrom idiopathic chronic fatigue. A progression ofME/CFS is seen in 10 to 20% of cases accordingto Peterson et al.  and 13 to 26% accordingto a systematic review by Cairns and Hotopf .Overall, according to the same systematic review,only 5%  will recover and the prognosis forseverely affected patients - those who are homeboundor bedridden - is even worse . Early managementof the illness appeared the most important determi-nant of severity [7, 87].
Illness severity, cognitive problems, a comorbidpsychiatric disorder [7, 122], or having comor-bid fibromyalgia , at baseline, are associatedwith a poor outcome. Psychosocial factors, smok-ing, personality or attitude show little relationshipto recovery. Spontaneous recovery is rare and onlyoccured in patients with an illness duration of lessthan 1 1/2 years . The recently publishedreview of work rehabilitation and medical retirementfound that recovery and substantial improvement areuncommon in patients if they have been ill for longerthan 2 to 3 years . This confirmed the conclusion bythe Inspectorate Work and Pay of the Dutch Ministryof Work and Social Affairs , that if patients havebeen on long-term sick leave for two years or moreand treatment with CBT did not make a difference,then the prognosis for a return to work is poor.
4.7. Work rehabilitation and medical retirement
People with ME/CFS are often unable to engage ineconomically productive work and typically requestsick leave as a response to their health crisis .Between 27% and 65% are reported not to be workingdue to ME/CFS according to a systematic review byCairns and Hotopf . The American CDC - Cen-ters for Disease Control and Prevention - reported
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that as many as 75% are not working due to ME/CFS. Men, people in older age groups and thosewho have been ill for longer are more likely to haveceased employment due to their illness . Accordingto research by TNO, an independent Dutch researchinstitute , only 7% of patients (n = 924) had neverbeen on long-term sick leav