Investigating the origins of GET (graded exercise therapy)

Lucibee

Lucibee

Senior Member (Voting Rights)
While reading the Ciba Foundation Symposium 173 papers (Wiley, 1993), I came across this quote from Peter White in one of the discussions (after Sharpe's presentation on Non-pharmacological treatments - p310):

"I wonder if Michael Sharpe believes that what he is doing is dealing with one part of the multidimensional problem, the psychological aspect, but missing out the physical aspects? Do you think a successful treatment would be one that combined the physical and the psychological sides together? It might include graded exercise therapy from David McCluskey, plus cognitive or dynamic psychotherapy at the same time."
Click to expand...

And thus, CBT/GET was born!

However, I looked back at David McCluskey's presentation, and there wasn't any mention of a graded exercise therapy, as he was presenting on pharamacological treatments. So I wondered if he had mentioned something at a previous symposium - and sure enough, he had.

This is from the British Medical Bulletin special issue on post-viral fatigue syndrome (McBride & McCluskey, April 1991):
Treatment of Deconditioning Phenomenon
The initial acute phase of a viral illness is characterised by avoidance of physical activity, as is indeed appropriate. However, the persistence of this behaviour when symptoms are slow to resolve proves to be maladaptive.[19] Those patients who have prolonged periods of rest followed by attempts at strenuous physical activity when they feel somewhat improved, characteristically have a recurrence of fatigue and myalgia which perpetuates and reinforces the exercise avoidance behaviour.[20] This leads to a marked deterioration in fitness to perform any significant exercise and this in itself may be associated with adverse psychological effects.[21] Thus many patients may fulfil the criteria for diagnosis of CFS regardless of the initial event that triggered the progressive decline in physical fitness. Treatment therefore must take into account the need to break this vicious spiral of deconditioning by initiating a graded programme of exercise which by small increments slowly restores the patient to physical fitness.[19,22] It may be difficult to fulfil the patients' expectations of what their level of fitness should be since patients have an exaggerated perception of their premorbid
level of fitness.[1] Some useful treatment methods for this aspect of CFS have derived from work in treating patients with fibromyalgia, a painful musculo-skeletal disorder of unknown aetiology which has many features in common with CFS.[23-25] Many fibromyalgia patients take little physical exercise and physical therapies such as progressive aerobic exercise, stretching exercises, moist heat and massage have proved useful. Avoidance of over exertion or stress is emphasised as this may exacerbate symptoms. It is noteworthy that habitual joggers and runners were resistant to developing fibromyalgic symptoms in studies which experimentally produced the symptoms in sedentary controls.[24]

Refs:
1 Riley MS, O'Brien CJ, McCluskey DR, Bell NP, Nicholls DP. Br Med J 1990;301:953-956
19 Wessely S, David A, Butler S, Chalder T. J R Coll Gen Pract 1989;39:26-29
20 Rose E, Jagannath P, Wessley S. The Practitioner 1990;234:195-198
21 Powell JB. J Am Med Assoc 1988;260:929-934
22 Ho-Yen DO. Br J Gen Pract 1990;40:37-39
23 Goldenbery DL, Simms RW, Geiger A, Komaroff AL. Arthritis Rheum 1990;33:381-387
24 Boulware DW, Schmid LD, Baron M. Postgrad Med 1990;87:211-214
25 Bennett RM. J Rheumatol 1989;19(Suppl. Nov):28-29
Click to expand...

But it's clear he was referring to previous work by Wessley.

McCluskey's other study (reference 1 in the above quote) looked at exercise capacity in patients with CFS and IBS vs normal controls and found a reduced aerobic work capacity in CFS patients compared with the other two groups. This paper is also cited in the PACE GET manuals.

McCluskey comments that patients seem to overestimate their previous exercise capability before becoming ill.

I then looked to see what White had done with this info. In 1997, he published his own trial of GET (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2126868/), which seems much more careful than the PACE version. Pts had to monitor their heart rate and make sure that they didn't go above 50% of max, and exercise intensity was modified accordingly.

In another paper in Physiotherapy (May 1998), this section caught my eye [my emphasis in itals]:
"The key to success is adherence to a structured and monitored programme, whereby they
do not overdo or exceed their exercise prescription, even on good days, but where they also
continue to exercise, albeit at a reduced level, on the bad days."

The 1997 trial doesn't mention reducing the level on bad days (but I suspect that's what happened). This is the relevant section:
Exercise treatment
Patients attended weekly for 12 weeks of supervised treatment and the next week's exercise prescription. All laboratory sessions were supervised by an exercise physiologist using basic principles of exercise prescription,[27] which were adapted for the patient's current capacity. Home exercise was prescribed on at least five days a week, with initial sessions lasting between five and 15 minutes at an intensity of 40% of peak oxygen consumption (roughly 50% of the maximum recorded heart rate). The daily exercise prescription was increased by one or two minutes (negotiated with the patient each week) up to a maximum of 30 minutes.
The intensity of exercise was then increased to a maximum of 60% of peak oxygen consumption. Patients were given ambulatory heart rate monitors to ensure that they reached but did not exceed target heart rates. The main exercise was walking, but patients were encouraged to take other modes of exercise, such as cycling and swimming. Patients were advised not to exceed prescribed exercise during a good phase. If patients complained of increased fatigue they were advised to continue at the same level of exercise for an extra week and increase when the fatigue had lessened.
Click to expand...

It seems striking to me that the GET eventually adopted in PACE seems particularly harsh and careless in the light of these earlier studies.

To me, it seems that the original intention of any exercise therapy was to manage the ill-effects of deconditioning that could potentially exacerbate symptoms of pain and fatigue, rather than trying to combat the underlying condition itself. Does that seem a fair assessment?
 
Lucibee said:
To me, it seems that the original intention of any exercise therapy was to manage the ill-effects of deconditioning that could potentially exacerbate symptoms of pain and fatigue, rather than trying to combat the underlying condition itself. Does that seem a fair assessment?
Click to expand...

Read the older papers by Wessely. That's where the idea comes from and I don't think the intent was as reasonable as you are proposing here.
 
The Wessely, Hotopf, Sharpe interpretation of the Fulcher, White study was;

"A key finding of the Fulcher and White study is that objective measures of physical fitness were not associated with outcome (i.e. clinical improvement was not related to improving physical fitness). Instead we suspect that the benefits were linked to confidence, predictability, and overcoming avoidance, lending support to our view that disability is more related to behavioural avoidance and confidence than simple physical fitness."

Not able to comment further at present.
 
strategist said:
Read the older papers by Wessely.
Click to expand...

As far as I can tell, Wessely's older papers are entirely theoretical. He cites no practical evidence to back it up. This is what he says in the 1989 JRCGP article:
Ideally a behavioural programme should be individually tailored, with agreed targets appropriate to the degree of initial disability.
However, it is likely to involve the following features:
1. Regular exercise, with which the patient can feel comfortable.
2. A graded increase in exercise, involving walking, swimming and so on.
3. Encouragement of exercises such as yoga and callisthenics.
4. Gradual exposure to all avoided activity.
5. Cognitive work to break the association between increase in symptoms and stopping or avoiding the activity.
6. Further cognitive strategies involving alternative explanations for symptoms.
For example, if the patient admitted to thinking 'I feel tired, I must have done too much', one might ask the patient
to look for alternative explanations, such as 'I may be tired because I haven't being doing much lately'
7. No further visits to specialists or hospitals unless agreed with therapist.
8. Involvement of a co-therapist.
Treatment is likely to involve six outpatient sessions.
Behavioural and symptomatic measures should be made before and after treatment, and at follow-up.
Click to expand...

It's back-of-envelope stuff!
 
In contrast to Wessely's approach, Dr Ho-Yen (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371214/) says the following (in 1990):

Approaches to treatment
It has been suggested that a new approach to the treatment of patients with post-viral fatigue syndrome would be the adoption
of a cognitive behavioural model.[3] However, many stages of this model appear to be based on patients who have been
ill for more than five years rather than those who have been ill for between three months and two years (Table 2). Those who
are chronically ill have recognized the folly of the approach which is taken by the recently ill and, far from being maladaptive,
their behaviour shows that they have insight into their illness. The model, which has been claimed as a new approach[3] is no
more than the conventional view - patients have been told for decades to 'get out and exercise' or 'go back to work. Indeed,
the truly new approach is that of moderating activity. This approach is based on patients' experiences that of all treatments,
rest is by far the most helpful.[9]
 
Last edited:
Lucibee,

There is an Australian maybe Physiotherapist ? who comes comes out of the woodwork every now and then and claims to have an early model of treating ME or CFS with exercise.

As an idea, I wonder how much Dr Lloyd may have had with propagating his work and given that Lloyd was at some of these meetings and in contact with some of the main players I wonder if it came from there?

Just an idea. I'm having a look to see what I can find.
 
@ukxmrv - I noticed that Lloyd was cited in some of the early papers. This one is cited in Wessely 1989 [ref 18 in the extract below]: Lloyd, Hales, Gandevia 1988 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1032921/

Following on from the previous quote:
"In general such advice is counter-productive, and must be set against the following:
- the harmful effect of disuse and inactivity on muscle function, in addition to respiratory and cardiovascular performance;[14]
- the psychological benefits of exercise on emotional disorders;[15]
- the adverse psychological effects of lack of exercise;[16]
- the deleterious psychological effects of avoidance of feared situations, as in agoraphobia;[17]
- recent evidence [from my mate in Australia] that dynamic muscle function is normal in patients with chronic fatigue syndrome, muscles being neither weak nor fatiguable.[18]"

I thought the issue was more with central fatigue rather than muscle fatigue per se. Not sure whether these types of study are going to assess that?
 
Last edited:
Lucibee said:
Pts had to monitor their heart rate and make sure that they didn't go above 50% of max, and exercise intensity was modified accordingly.
Click to expand...

The problem is that if you limit the exertion to 50-60% of max heart rate, you aren't going to build any fitness. This type of therapy is purely psychological.

The same goes with the fad of high step counts - it is intensity, not step counts that builds fitness or strength. Higher activity might lead to weight loss, but we're talking about an average of 15,000 steps per day to have significant weight loss versus the more effective approach of changing one's diet.
 
adambeyoncelowe said:
Yes. Him. Another one with a magic cure only he knows, but he won't share the answers unless he gets paid. *rolls eyes*
Click to expand...
Oh he invented graded excercise, until people told him that was bad. Then he had invented pacing. It’s all in how you look at it.

ETA: actually I feel a little bad for him. His account of the beginning is that a university asked him to write a thing, and, iirc, without any clinical trials experience, training, or assistance he conducted an experiment and wrote it up. It wasn’t what the university wanted, but rather than explain, teach, or help, they evidently told him to buzz off.

He seems to be a little stuck, but that’s a normal human thing.
 
Last edited:
Snow Leopard said:
it is intensity, not step counts that builds fitness or strength
Click to expand...
This is correct wrt. resistance training (you need to train around 70-80% of max. strength in order to increase muscle mass), but a GA1 training (~ 75% max. heartrate), for instance, is an aerobical training for improving endurance, so it's not about intensity alone, and GA1 is a very important part of an endurance training.

50-60% would be a recovery training and therefore it's not supposed to increase strength/endurance/capacity. An exception is if you start with a training. Any training for the first 6-8 weeks will show improvement; this is about building "neurogenic structures" for a better "communication" between brain and muscles.

Whenever reading those GET exercise papers and manuals, I really wonder about their "knowledge" about sports medicine.
 
The Workwell foundation seems to know their stuff...whenever I read GET things, this seems very different. By the way, who were the professionals who set up the GET plan, and what was their aim? It doesn't seem to be anything I came across during my training phase. But that doesn't have to mean anything.
 
Lucibee said:
To me, it seems that the original intention of any exercise therapy was to manage the ill-effects of deconditioning that could potentially exacerbate symptoms of pain and fatigue, rather than trying to combat the underlying condition itself. Does that seem a fair assessment?
Click to expand...
If it was really aimed at overcoming true deconditioning, then I would agree. If an oblique reference to PwME being deconditioned patients falsely believing they had an illness they could not exercise themselves better from, then I would disagree. And I don't know which it is.
 
Deconditioning is not common in ME anyway. While all this was going on, none of them actually asked patients if they were deconditioned (or even what their coping styles were). It was assumption after assumption. They said what they assumed to be true about patients, then stated what they assumed would fix it.
 
You must log in or register to reply here.
Back
Top Bottom