British Medical Journal coverage of the PACE Trial: 23 February 2011

From the British Medical Journal, 23 February 2011

BMJ 2011; 342:d1168 doi: 10.1136/bmj.d1168 (Published 23 February 2011)
Cite this as: BMJ 2011; 342:d1168

CBT and graded exercise are safe and effective treatments for chronic fatigue syndrome

Lancet 2011; doi:10.1016/S0140-6736(11)60096-2

Cognitive behavioural therapy (CBT) and graded exercise are the best treatments for chronic fatigue syndrome, according to a rigorous trial of four different options. Both treatments looked safe when added to specialist medical care and worked better than adaptive pacing therapy or specialist care alone. The 641 participants were treated for six months and followed up for a further six months. All groups improved, but by the end of the trial patients treated with CBT or graded exercise had significantly less fatigue and significantly better function than any of the other groups. All secondary outcomes pointed in the same direction, including patients’ “own impressions” and graded exercise therapy both doubled the odds of being much or very much improved, relative to specialist care alone (odds ratios 2.2, 95% CI 1.2 to 3.9; and 2.0, 1.2 to 3.5).

Adaptive pacing was the least successful active treatment in this trial, despite patients’ high expectations. Some patient groups favour adaptive pacing because it teaches patients to live within their capabilities (adaptation) rather than risk exacerbating fatigue by increasing activity. Graded exercise therapy and CBT, both of which encourage patients to do more, did not worsen symptoms in this trial, and serious adverse events were rare in all groups. Only a handful of patients got much worse during or after any treatment.

Patients with chronic fatigue syndrome have nothing to fear from CBT or graded exercise, say the authors. Both work as a bolt on to specialist care, although their overall effects looked modest. Less than a third of patients were cured by either treatment (30% (44/148) after CBT and 28% (43/154) after graded exercise therapy).