NICE Statement about graded exercise therapy in the context of COVID-19. 

NICE is aware of concerns about graded exercise therapy (GET) for people who are recovering from COVID-19. NICE’s guideline on ME/CFS (CG53) was published in 2007, many years before the current pandemic and it should not be assumed that the recommendations apply to people with fatigue following COVID19. The recommendations on graded exercise therapy in CG53 only apply to people with a diagnosis of ME/CFS as part of specialist care, and CG53 is clear that this should be part of an individualised, person-centred programme of care, with GET only recommended for people with mild to moderate symptoms.
As the guideline is currently being updated, it is possible that these recommendations may change. The evidence for and against graded exercise therapy is one of the important issues the guideline committee is considering. NICE plans to consult on the updated guidance in November 2020.
NHS England has recently published guidance on After-care needs of inpatients recovering from COVID-19 that includes advice on fatigue.
July 2020
 
The ME Association  gives the background to the NICE Statement in their article concerning the 'Clinician's Letter to NICE Results in Statement on Graded Exercise for Post-Covid-Syndrome'.
The MEA explained that the NICE statement was in response to a detailed letter to NICE that was prepared by Dr Charles Shepherd and Dr William Weir several weeks ago and which was signed by other members of the NICE ME/CFS clinical guideline committee.
The letter pointed out that recommendations in the current (2007) NICE guideline regarding the use of GET in ME/CFS could cause serious harm if applied to people who are failing to recover from COVID-19 and who are experiencing Post-Covid Syndrome and other complications.
The letter also pointed out that there is a need for guidance from NICE about the use of Pacing as a sensible and safe alternative to Graded Exercise Therapy in respect of Post-Covid Syndrome.
 
The MEA article  also tells us that knowledgeable physiotherapists and occupational therapists, and the MEA, have all produced helpful guidance in this regard, but the message about the dangers of Graded Exercise Therapy, and the increased need for individualised, patient-centred, care is not being taken up by official sources of information.
The article also gives Dr Shepherd’s detailed response to the NICE Statement, plus links to -

• The NICE Statement about GET and Covid-19

• ME Association Statement on GET and the current NICE guideline.
• MEA Leaflet on the management of Post Viral Fatigue Syndrome and Post-Covid Syndrome.

 
In June, the MEA announced The New NICE Clinical Guideline on ME/CFS to be Published in April 2021. 

Dr Charles Shepherd, Hon. Medical Adviser to the ME Association, and other M.E. experts, clinicians, and patient representatives, had continued to work on the new clinical guideline via remote meetings until NICE made the decision to suspend them as resources were directed towards the Covid-19 pandemic.
The meetings were recently reinstated and work now continues. Stakeholders can expect to receive the new draft guideline for comment and review from 10 November this year.
 
The recent Letter to Stakeholders was given on the MEA website -
Dear Stakeholder, 
As you will be aware, because of the need to prioritise work on COVID-19 guidance and to avoid drawing frontline staff away from their clinical work, NICE cancelled all guideline committee meetings. This included meetings for the ME/CFS guideline.
We have now rescheduled the remaining committee meetings for this guideline and agreed a revised timeline. This means that the consultation on the draft guideline will now start on 10 November, and the guideline will now publish on 21 April 2021.
Katie Stafford, Senior Guideline Coordinator, 24 June 2020
 
For further background information, see our previous  NICE Guidelines: Coronavirus Covid-19, and ME/CFS  blog dated 26 April.

• NICE (National Institute of Clinical Excellence) publishes first rapid COVID-19 Guidelines.  

NICE announce - These guidelines have been developed to maximise patient safety whilst making the best use of NHS resources and protecting staff from infection. The guideline has been developed using the interim process and methods for developing rapid guidelines on COVID-19 and recommendations are based on evidence and expert opinion.   Because we are using a different approach in order to develop these guidelines quickly to support frontline NHS staff, we will be reviewing them each week as new evidence, policy and practice emerges.

The first NICE rapid guidelines were published on 20th March, with further guidelines published since then. 

The new NICE clinical guideline on ME/CFS ME/CFS: diagnosis and management - NICE Guidance in Development. 

The ME Association’s Covid-19 key information and guidance of 30 March, included a NICE Guidance announcement by Dr Charles Shepherd, Hon. Medical Adviser, of the ME Association.
In my capacity as a member of the committee that is preparing the new NICE clinical guideline on ME/CFS I took part in two days of video conferencing meetings on 17 and 18 March. 
However, NICE has decided to halt all further work on this guideline due to many of the clinical staff on the committee (myself included) being heavily involved with our duties in relation to coronavirus.
My personal view is that it now seems very unlikely that we will be able to meet the current target of publishing the new NICE guideline in December 2020.
NICE has also been contacted about guidance on how people with serious pre-existing health problems should be managed if they must be admitted to hospital with coronavirus infection.

• #MEAction announce - 'NICE Guidance Delayed Until Further Notice, due to Covid-19'
The National Institute of Health and Care Excellence (NICE) have suspended work on all guidelines currently in development due to the Covid-19 pandemic, including their update of the ME/CFS guideline, originally due to be published October 2020 and recently delayed by NICE to December 2020.
#MEAction’s report includes the full email from NICE, as received by all ME/CFS Guideline stakeholders.

Dear Stakeholder,
We wanted to update you on how NICE is working to support the NHS and wider health and care sector at this challenging time, and to provide more details on how the COVID-19 pandemic is affecting our normal ways of working.
During this period of emergency, NICE has adapted its priorities to support the NHS, local authorities and the wider health and social care sector to tackle COVID-19. We will only publish guidance that is therapeutically critical or focused on COVID-19-related issues.
The stakeholders and advisory committees involved in the development of our guidelines include a large number of frontline staff. We know that their priority in this crisis is caring for patients. We do not want to draw them away from this vital work.
For this reason, we have cancelled all guideline committee meetings and we will not be publishing any draft or final guidelines until further notice (except for COVID-19 rapid guidelines – see below).
At present we are not able to confirm the revised timelines for each guideline. We will be in touch to provide further information as soon as possible. For more information in the meantime, please visit our dedicated webpage.
COVID-19 rapid guidelines
We are working closely with NHS England and NHS Improvement to develop rapid guidelines on topics relevant to the management of COVID-19. These will be published weekly and will focus on a range of clinical settings.
In addition, we are producing rapid evidence reviews on medicines used to manage COVID-19 and its symptoms.
All of our COVID-19 guidelines and evidence reviews will be published on the NICE website. Enquiries about this work should be sent to nice@nice.org.uk
Kind regards, Katie Stafford, Senior Guideline Coordinator, Centre for Guidelines

#MEAction supports NICE’s aim to keep healthcare professionals on the frontline throughout this crisis and understand that professionals involved in guideline development are commonly also working in the NHS.  Also, they note that this will be a very challenging time for everyone across the UK and the world and a fully comprehensive stakeholder consultation on the guidelines (due to take place from 30th June) would be next to impossible.
#MEAction are still very concerned that the existing guidance remains in place, including the harmful recommendation of Graded Exercise Therapy (GET).

• Coronavirus and Fatigue

The ME Association tell us of a Letter of Concern initiated by Physios for ME, a group of physiotherapists with a special interest in the neurological disease, and signed by members of Forward ME. 

The MEA explained that the letter The letter from Forward ME and Physios for ME criticising the OHFT guidance., sent to the Oxford Psychosocial Group called for the withdrawal of an inaccurate and potentially harmful document about which they had received many complaints.   

As well as highlighting the issues with the leaflet, the letter sets out clear evidence for pacing, the symptom management people with M.E. tell us they find most helpful.

• Action for M.E. Chief Executive, Sonya Chowdhury, has signed an open letter calling for the withdrawal of an inaccurate and potentially harmful NHS Trust resource. 

Oxford Health NHS Foundation Trust has produced a leaflet, which says it is “one of a series about Coronavirus and mental health. The leaflets contain information about how the Coronavirus outbreak might affect your mental health, how to look after yourself, what to do if a problem persists, and where to find further information.”
However, we are extremely concerned that this leaflet:

• conflates post viral fatigue with M.E.
• purports to provide information for post-COVID-19 rehabilitation but is predominantly comprised of rehabilitation advice for M.E.
• provides is incorrect or misleading information, which is potentially detrimental to patients and may result in deterioration and exacerbation of disability, by recommending graded exercise.

• Action for M.E.’s 2019 Big Survey revealed that only one in ten people who did GET with an M.E./CFS Specialist said it helped them manage symptoms. Almost half said it had a worsening effect with others saying it had no different.
The letter has been drafted by Physios 4 ME, a group of physiotherapists with a special interest in M.E./CFS who have recently joined Forward-ME.  As well as highlighting the issues with this particular leaflet, the letter sets out clear evidence for pacing, the symptom management people with M.E. tell us they find most helpful.
We are also working with the other signatories to produce information which will be provided to the Foundation Trust to ensure they are aware of the latest evidence and patient feedback.

The Worcestershire Health & Care NHS Trust  were using this Oxford Psychosocial Group Coronavirus and Fatigue leaflet under the Mental Health Support topic on their website, but it has now been deleted from this location.

Join us at our social gatherings in 2020.
All people with M.E., CFS, FMS, and their carers, friends and relatives, are welcome at all Worcestershire M.E. Social Group gatherings - please join us at whichever suits you.  Join us for a bite to eat, or just a cuppa and chat.
All 2020 Social Gatherings are shown on our meetings page.  We have Group Lunches from January to November and Afternoon Cafe Meetings from May to August, at various locations throughout Worcestershire.

For your convenience, download our Group Handout, containing 2020 Social Gatherings dates and venues.
 
ME Awareness Week in May - Monday May 11 to Sunday May 17. 
Join us at our Afternoon Café Meeting on Thursday 14 May, at the Olive Grove Café (David's Garden Centre by Cherry Lane, Martin Hussingtree, Ash Lane, Worcester, WR3 8TB)

Look out for the #Millions Missing Birmingham announcements.  Last year held on Friday 10 May in St Philip’s Cathedral Square, Birmingham.
 
New NICE Guideline on ME/CFS is delayed until the end of 2020.
The publication date will be 9 December 2020.  Last month, the ME Association (MEA) published a letter received from National Institute of Health and Care Excellence (NICE) announcing this date.

The MEA gives detailed information about the NICE Clinical Guideline review.
For more information about the guideline review, visit the NICE section of the ME Association website.

Have you received or been offered Cognitive Behavioural Therapy (CBT) and/or Graded Exercise Therapy (GET) in the UK since 2007?

The Forward ME group of charities has launched a survey, having been asked by the National Institute of Health and Care Excellence (NICE) to gather evidence and experiences.

ME Research UK (MERUK) CEO, Simon Phillips, welcomed the launch of the survey, adding:
As one of the funders of the CBT and GET Patient Survey and as an active member of the Forward-ME Group, ME Research UK encourages all those who have undertaken or were offered CBT or GET in the UK since 2007 to take this opportunity to contribute before the end of January 2019. This will allow Forward-ME to submit the results to NICE for them to use as part of their review of the current Guideline. We will await the results of Oxford Brookes University’s analysis of the results with keen interest.

The ME Association (MEA) explain the deadline:
The deadline for completing the questionnaire is the 31st January 2019, to meet the very narrow time frame set out by NICE. 
Unfortunately, this also means that Forward ME do not have the time or capacity to send out/accept paper copies. We will make it very clear to NICE when we submit the report that those unable to complete the survey online, including many severely affected people, have not been able to take part.
The survey is however designed to allow a carer, parent or another person to fill it in on behalf of someone else if they are unable to do this themselves.

Join in discussions on social media groups.

Information from the Worcestershire NHS CFS/ME Local Multi-Disciplinary Team (LMDT): Nice guidelines (2007) suggest that the most effective treatments are Cognitive Behavioural Therapy (CBT) to help improve the way you feel about the condition, and Graded Exercise Therapy (GET) to gradually build up exercise tolerance and improve fatigue levels. The principles of these therapies underpin the treatment provided by the Worcestershire CFS/ME Service.

Please sign and forward petition:  “Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW”. 
Expected Publication date by NICE: 14 October 2020.
NICE has promised to review its current guidelines on ME/CFS, which is not scheduled to be completed until October 2020.  Meanwhile it has left the current guidelines in place, despite the recommendations for treatments that are known to be harmful.  

ME/CFS NICE Guideline updates from ME Association (MEA), Action for ME (AfME), Forward ME, and ME Research UK (MERUK).

MEA:  NICE ME/CFS Guideline Review: Publication of revised Scope, comments, and committee appointments | 16 October 2018.

AfME:  NICE publishes final scope for M.E./CFS guideline.
October 16, 2018.  The National Institute for Health and Care Excellence (NICE) has published its final scope for its updated guideline on M.E./CFS, along with consultation comments and committee appointments.

MEA:  Forward ME – Stakeholder deliberations over NICE Scope for ME/CFS | 22 October 2018.

AfME:  NICE guideline scope and committee: update & comment.
October 25, 2018.  
 
MERUK:  NICE ME/CFS Guideline Committee - ME Research UK’s Comment.
Posted on 29 Oct 2018.
ME Research UK joined other charities and those affected by ME/CFS in welcoming the long-awaited review of the NICE Guideline on ME/CFS.  Given the concerns expressed by many about the scope and content of the current Guideline, this review is vitally important and ME Research UK, as a stakeholder, has submitted its views to NICE during its consultation period.
We agree that it is important to listen and understand the views of a range of experts in order to ensure that the revised Guideline provides clarity for everyone who is affected by it - patients and clinicians - but the Guideline must be based on the best available research and the replacement Guideline written with objectivity.
ME Research UK wishes to express its disappointment with the current appointment of a comparatively small number of members of the ME/CFS Guideline Committee who have expertise on the biomedical basis of ME/CFS when compared to those whose background appears to favour the bio psychosocial model. Given the increasing evidence of a biomedical origin of the illness and the current uncertainty, for example, of the soundness of the PACE trial, this is to be regretted. 
We look forward to following the progress of the committee with interest and we hope that the views of those with biomedical expertise are heard and that the revised Guidelines will improve the situation for the many, many thousands of people affected by this illness.

ME Association Statement re: NICE ME/CFS Guideline Review and Committee Appointments | 09 November 2018. 
by Dr Charles Shepherd, Hon. Medical Adviser, ME Association.
The ME Association has always been very clear on the position we take on the current (2007) NICE clinical guideline.
We believe that many of the key recommendations are unfit for purpose - especially those regarding the use of CBT and GET for everyone with mild or moderate ME/CFS.
We have played a key role in persuading NICE that a new guideline is required. The new guideline must recognise that ME/CFS is a serious multisystem disease and not a psychological illness.

PACE trial and its effect on people with ME - debated by MPs in Westminster Hall on 20 February.
Video (11.00 - 11.30 am), and official Hansard transcript from the PACE Trial debate now available.
 
Action for ME gave a summary, and the ME Association a detailed report.

Carol Monaghan: SNP MP leads debate on ‘one of the biggest medical scandals of the 21st century’.

Discussion on Science for ME website.

NICE news article - NICE announces next steps in updating its guideline on ME/CFS.

A workshop last month with stakeholders marked the formal start of NICE’s collaborative work to update its 2010 guideline on the diagnosis and management of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
 
NICE Guideline - ME/CFS : Diagnosis and Management
A New Guideline is in development, with expected publication date: 14 October 2020.  This Guideline will fully update (CG53)

 
Forward-ME members discussed the NICE Guideline when they met on 10 January, a week before the NICE Guideline Stakeholder Engagement workshop.   Forward-ME is a collaboration of ME/CFS charities - chaired by the Countess of Mar.

 
Reports following the workshop:

• Dr Charles Shepherd, the ME Association’s Medical Adviser summarised the key points;  and the MEA announced the NICE News item - 
• Sue Waddle, Vice Chair of ME Research UK (MERUK) attended the workshop and gave her comments in the MERUK NICE Guideline Report
• Action for M.E.’s report on their involvement at the NICE guideline meeting, and further report -

 
 
Information from the Worcestershire NHS CFS/ME Service website:
Worcestershire Health & Care NHS Trust Extract from ‘Family & Friends Area’ -
Treatments for CFS/ME
Nice guidelines (2007) suggest that the most effective treatments are Cognitive Behavioural Therapy (CBT) to help improve the way you feel about the condition, and Graded Exercise Therapy (GET) to gradually build up exercise tolerance and improve fatigue levels. The principles of these therapies underpin the treatment provided by the Worcestershire CFS/ME Service.

The National Institute for Health and Care Excellence (NICE) announced on 20th September 2017 that it is planning a full update of its guideline on the diagnosis and management of CFS/ME.

• ME Association: Breaking News: NICE decides to Fully Update its guideline on ME/CFS!
• Action for M.E.: NICE guidelines on CFS/M.E. to be reviewed
• ME Research UK: NICE CFS/ME guideline to be updated
  
• NICE announcement
  
• NICE Guideline: Clinical guideline [CG53]
  
• The Times: Mutiny by ME sufferers forces a climbdown on exercise treatment | 25 September 2017

15,180 people signed the ME Association (MEA) national petition, addressed to Sir Andrew Dillon, Chief Executive, NICE, calling for a complete review of the NICE guideline for ME/CFS.  This included many Worcestershire people who signed, many of whom gave their comments.
The 2007 NICE Clinical Guideline has been checked by NICE for the need for an update and the NICE CFS/ME Guideline Registered Stakeholders were invited to comment on NICE’s surveillance consultation - they were given 14 days, from 10 - 24 July to voice their concerns.

LocalME (an online forum for local ME group contacts across the UK) responded - they had managed to receive an extension until 31 July.  The MEA announced Stakeholder submissions from Action for ME (AfME), Forward-ME, Invest in ME Research, LocalME, the MEA, Tymes Trust, and many more.
 
National Petition -
ME Association petition represents biggest expression of no confidence in a NICE guideline ever recorded | 26 July 2017
www.meassociation.org.uk/2017/07/me-association-petition-represents-biggest-expression-of-no-confidence-in-a-nice-guideline-ever-recorded-26-july-2017/
 
Comments - 
www.meassociation.org.uk/wp-content/uploads/MEA-Petition-Comments-24.07.17-1.pdf
 
NICE surveillance consultation -
www.nice.org.uk/guidance/CG53/documents/surveillance-review-proposal
 
Stakeholder submissions -
www.meassociation.org.uk/2017/07/the-nice-guideline-consultation-uk-stakeholder-submissions-27-july-2017/
 
LocalME -
see attached file below

This is your opportunity to voice your concerns. 

The ME Association has today [10 July] launched a national petition that aims to demonstrate to NICE (National Institute for Health and Care Excellence) that people with CFS/ME are not happy with the current guideline or the way in which the current review is being conducted.
Action for ME are also directing people to the MEA national petition.

Please sign the petition, add your comments if you are able to, and share/forward this blog.

• ME Association Petition: The NICE guideline for CFS/ME is not fit for purpose… | 10 July 2017
• Action for M.E. to NICE: guideline must be reviewed 10 July 10 2017