This has a been good week for advocacy. It’s showing that smart advocacy works. Twice advocates went straight back into “the system” looking for results and twice – once with the PACE trial and here with AHRQ report in the U.S. – they got them.
Spearheaded by Mary Dimmock who for years has lead the fight to secure a better definition, advocates asked the AHRQ to reanalyze it’s finding regarding CBT and GET.
The AHRQ agreed to test definition against definition
As part of the Pathways to Prevention (P2P) project, the AHRQ had been tasked determined with determining which treatments were effective for chronic fatigue syndrome (ME/CFS). The group applied tough, tough standards – so tough that it rejected 90% of ME/CFS studies, and only 30 treatment studies made it to the analysis stage. Of those only four studies were deemed “high quality”.
Since most of the trials that made it to the final analysis were small, unreplicated studies, the AHRQ deemed the evidence insufficient to say anything about any treatments other than CBT/GET.
That lead to some strong outcries from some advocates, including some of the same advocates requesting another secondary analysis. The AHRQ was too tough, some said, for such an underfunded field. It made ME/CFS researchers and the chronic fatigue syndrome (ME/CFS) field look bad. That same rigor the AHRQ applied to its first analysis, however, paid dividends this time.
CBT and GET didn’t fare so well in the initial report. The AHRQ stated it had only “moderate” confidence that CBT was able to reduce fatigue or produce “global improvement”, and had low confidence it was able to improve overall functioning, enhance quality of life, increase working hours, or reduce work impairment in ME/CFS.
Mary Dimmock noted the conclusions had a flaw. The P2P report stated that the Oxford definition was so broad – only requiring that unexplained fatigue be present – that any study using it was likely to include people who did not have ME/CFS.
The Oxford definition is an anomalous definition used mostly by a small group of CBT/GET researchers based mostly in the U.K. and the Netherlands. The vast majority of researchers have always used the Fukuda definition for research but in the CBT/GET field the Oxford definition has dominated. The P2P report recommended that the Oxford definition be trashed.
In their CBT and GET analyses, though, the AHRQ treated the Oxford definition like it was valid, lumping studies using it and the Fukuda definition studies together. When that logical inconsistency was pointed out they agreed to reanalyze the CBT and GET studies, comparing studies using the Oxford definition to those using Fukuda definition.
The expectation was that studies using the Oxford definition would fare better than those using the stricter (but still not particularly strict) Fukuda definition, and, indeed, the AHRQ’s conclusions regarding the effectiveness of CBT/GET in ME/CFS changed dramatically once the analysis was done.
Results
For the first time the AHRQ panel asked these questions”
Does CBT Increase Functioning In Fukuda Patients?
In the original report the AHRQ found “low evidence” that CBT does not improve functioning at all. When studies using the Oxford definition were removed the four studies left found that two studies produced benefit and two did not The AHRQ downgraded their evaluation of CBT stating that given the inconsistent results, the imprecise nature of the results and the mixed quality of the studies made it impossible for them to determine if CBT was effective or not in a Fukuda patient.
Does CBT Reduce Fatigue in Fukuda Patients?
When studies using the Oxford case definition were removed, the AHRQ was left with four fair-quality studies, three of which found benefit (n=327), one which found no benefit (n=65), and one poor-quality study finding no benefit (n=58). In general the trend was upwards but the quality of the studies was only fair: the AHRQ determined that this body of work provided a “low strength of evidence that CBT improves fatigue”.
Does CBT Improve the Employment Status of Fukuda Patients?
A starker difference was found in the effects of CBT/GET on employment. Once the AHRQ removed the Oxford definition studies they found that CBT had no impact at all on employment.
Does CBT Improve Quality of Life in Fukuda Patients?
Because all three studies measuring quality of life already used the Fukuda criteria, the AHRQ’s assessment remained the same. Two of the three found no effects on quality of life, leading the AHRQ to conclude that the strength of evidence that CBT/GET did not affect quality of life was low.
Does CBT Result in Global Improvement in Fukuda Patients?
Only two studies (but containing 540 people) assessed global improvement. Both the Oxford and CDC definition studies found improvement in global improvement but the authors deemed the evidence insufficient to make a recommendation.
Does Graded Exercise Therapy Improve Outcomes in Fukuda Patients?
Four trials, three using the Oxford Definition and one using the CDC definition were included in the original analysis. The results from all the trials were consistent; there was moderate strength of evidence that GET improved functioning (4 trials, n=607) and global improvement (3 trials, n=539), low strength of evidence that it reduced fatigue (4 trials, n=607) or decreased work impairment (1 trial, n=480).
When they removed the Oxford trials from the analysis, the one study left showed improvement, but it alone provided insufficient evidence that GET was successful in Fukuda patients.
Conclusions
The AHRQ re-analysis caused it to downgrad its assessments of CBT/GET in ME/CFS
The AHRQ re-analysis of the CBT and GET trials resulted in it downgrading its recommendations significantly. In two cases (CBT’s effects on functioning and employment) the reanalysis suggested that CBT was less effective in Fukuda patients than in Oxford criteria patients.
In other cases (CBT – Global Improvement; GET – functioning, global improvement, fatigue) the Fukuda studies suggested that some improvements did occur but too few studies were done for the AHRQ to make a recommendation.
In the end the only mildly positive statement the AHRQ could make was that there was low strength of evidence that CBT improved fatigue in ME/CFS. Otherwise it found no evidentiary basis for the use of CBT/GET in ME/CFS. It didn’t state that these techniques are helpful or not helpful; it simply stated that they are unproven.
Meanwhile we should note that the Fukuda definition, which has been the gold standard definition in ME/CFS research for over 20 years is nothing to shout about either. It’s more than past time for a new, statistically based research definition for ME/CFS. What better way to start the NIH’s new era of ME/CFS research than with a definition that works?
Now What?
The AHRQ has spoken. Now that they have basically demolished the idea that anything positive can be said with certainty regarding the effectiveness of CBT/GET in ME/CFS where do we go from here?
The AHRQ, we should note, applies the most rigorous standards of any review body.
Will medical websites be open to a new interpretation of CBT/GET?
One might assume that the more rigorous reports might be authoritative in the field. The AHRQ is highly respected but it’s competing with the Cochrane Reports which are less rigorous and probably more used.
The Cochrane Reports probably include many studies that AHRQ rejected in their reports and are cited frequently.
A look at major medical websites indicates that the idea that CBT/GET is not just an effective treatment but is the only effective treatment for ME/CFS is deeply embedded in some.
These websites tend to provide rudimentary, imprecise analyses of treatments. They don’t get into the niceties regarding different definitions. Time will tell, but it may be difficult to get them to change their ways. Let’s look at what four prominent medical websites say about CBT/GET and ME/CFS
UpToDate
Up to Date may be the most critical website since it’s commonly used by physicians seeking to get up to date information on treatments. A pay to play website, UpToDate probably provides the most comprehensive overviews of treatments on the web. It’s CBT/GET section starts off with some proviso’s:
“a systematic review of 35 randomized trials evaluating therapies for SEID/CFS concluded that counseling therapies and graded exercise therapy may have benefits for some patients with SEID/CFS [5]. However, neither of these modalities is curative.”
But then goes on to state that
“Cognitive behavioral therapy (CBT) has been effective in patients with SEID/CFS”.
The first CBT and GET trial UpToDate cites is the PACE trial. It notes that the trial involved 600 plus patients – thus providing automatic validation for many practitioners – but provides no hint that any issues exist with this trial. It then provides the kind of imprecise summary so common in medical websites. UpToDate states that
“CBT in combination with specialist medical care (in the PACE trial) was associated with less fatigue and better physical function compared with specialist medical care alone”
without noting that the effects weren’t considered clinically significant. UpToDate does the same thing with the GET arm of the PACE trial stating that
“GET in combination with specialist medical care was associated with less fatigue and better physical function compared with specialist medical care alone”
without noting that the step test results indicated that the participants were still severely disabled.
In another study UpToDate stated that CBT in combination with managed care was more effective than managed care without saying how more effective it was
Each of the vague statements UpToDate makes could be and probably are often interpreted to suggest that CBT/GET is really helpful in ME/CFS.
UpToDate then cherry-picked studies to cite one indicating no cardiopulmonary problems exist in ME/CFS and that exercise does not increase symptoms. It could have easily cited studies showing the opposite but chose to cite studies that reflected its conclusion – that exercise therapy is effective in ME/CFS.
The American Family Physician
The American Family Physician states
“There is substantial evidence for two treatments for CFS: cognitive behavior therapy (CBT) and graded exercise therapy.”
Unless you’re doing the kind of analysis that the AHRQ does, that is probably a true statement. It goes on to say that:
“Persons diagnosed with chronic fatigue syndrome should be treated with cognitive behavior therapy, graded exercise therapy, or both. Cognitive behavior therapy and graded exercise therapy have been shown to improve fatigue, work and social adjustment, anxiety, and postexertional malaise.”
AFP obviously goes far, far beyond the AHRQ’s conclusions, and even goes far beyond the Cochrane Report’s conclusion. It hardly attempts to produce a balanced report of CBT or GET’s limitations or their very moderate effects.
WebMD
WebMD is a bit more enlightened. CBT is not presented as a cure but as a coping mechanism that can help some people.
“(CBT) is a type of counseling that has been shown to help some people who have CFS feel less tired” that “teaches you how to change the way you think and do things. These changes can help you better cope with fatigue and other symptoms.”
With regard to GET, WebMD states that it may help some people but suggests that those who are severely ill stay away.
“Unless your CFS is severe, try a graded exercise program, starting out with gentle and easy movement. Start with as little as 1 minute, and slowly add more over days or weeks. Studies have shown that a carefully planned graded exercise program can help some people with CFS regain their strength and energy and feel better. “
The Centers For Disease Control
The CDC has muted its recommendations for CBT and GET considerably in recent years. The CBT section is now posted in the Improving Health and Quality of Life section (not the Treatment section). No mention of a cure is made. The CDC contextualizes CBT as a way to effectively pace and reduce stress.
For CFS patients, CBT can be useful by helping them pace themselves and avoid the push-crash cycle in which a person does too much, crashes, rests, starts to feel a little better, and then does too much once again. Often, CBT is prescribed along with other therapies to help CFS patients manage activity levels, stress, and symptoms. CBT can help CFS patients better adapt to the impact of CFS and improve their ability to function and their quality of life.
The GET section is now posted in the management (not the treatment) section. The stated goal is not to cure ME/CFS but to improve fitness and contains many qualifiers: GET can help “some” patients “manage” their illness, and exercise should stop before patients get tired and ME/CFS is reactivated. It has a separate section for the severely ill.
Gradual, guided physical activity can help some CFS patients manage the illness. Appropriate rest is an important element of GET, and patients should learn to stop activity before illness and fatigue are worsened.
The end point of each GET session….. should be reached before the patient becomes tired….Appropriate goals are to prevent tiredness, to avoid activating the syndrome, and to increase overall fitness.
The CDC has been thought of as a leader that other websites will follow but this short analysis suggests this is not so. The CDC has the mildest recommendations regarding CBT and GET but its recommendations should indicate there is now almost no evidentiary base to conclude that CBT/GET are effective in ME/CFS.
Conclusions
Hopefully the AHRQ’s reanalysis will help blunt the emphasis given to CBT/GET in this field. What this field really, really, really needs, though, is to end the dominance of European government funded behavior based trials. No two entities should be able, simply by pouring money into a field, to dictate its treatment options, but that’s essentially what’s happened in ME/CFS.
The NIH needs to step forward and fund clinical trials
The major medical websites will shift their emphasis when good treatment trials provide evidence that other treatments are effective in ME/CFS. The NIH can begin this process by funding Ampligen and Rituximab trials.
One successful Ampligen trial – which could be set up quickly and easily – would be enough to get FDA approval. Rituxmab would take longer but the NIH has a great deal of experience running Rituximab trials.
With the AHRQ re-analysis in hand, approvals for Ampligen and Rituximab, if they should occur, could go a long way to blunting the effects that years of over emphasis on CBT/GET have had. The NIH has said it’s serious about ME/CFS; funding these two trials would indicate that it is. It’s time for the U.S. to step up.
As a clinical psychologist with severe FM, I’m afraid that I always thought that these supposed CBT positive effects for ME and FM were suspect. It’s a powerful technique but positing effects on biological disorders…maybe not. You can get the best of CBT by following these two statements. Watch what you say to yourself. Don’t catastrophize.
That’s really good advice. I hate to see that kind of advice buried under the understandable concerns about CBT being the only recognized treatment for ME/CFS.
I’ve come to conclude that at least with me catastrophizing probably came with the arousal I’ve noticed with ME/CFS/FM and my quality of life and my health to a small extent is better when I don’t do it.
It just needs to be put in its proper place.
Great reporting, once again, Cort! What would our community do without you!
Thanks but the real thanks goes to Mary Dimmock for spearheading the effort. I thought it would never succeed – I thought the AHRQ would never agree to re-analyse their data but Mary went for it and they did. Now that’s good advocacy!
Understanding this illness would be the best cbt. I guess everyone could do with more cup is half full but the root of the problem is ever present unending exhaustion. As far as get, when I do mild exercise I usually have to take a day or two off. One thing I do believe is don’t push yourself too hard, you will pay a major price with this illness. I did.
Cort, I follow your articles with great interest even though most of my research energy is put into Ehlers-Danlos Syndrome. People familiar with EDS know that there is significant overlap with CFS/Fibro type symptoms (and there is considerable debate as to whether they should be included or excluded as separate entities).
Since the information about the manipulated data on the effectiveness of CBT in CFS has just come to light, are there any similar revelations about CBT’s effectiveness in fibromyalgia treatment (as it is often recommended for both)?
P.S. Since this is my first post on your site, I also want to thank you for all of your efforts in being a spokesperson for these often misunderstood and dismissed conditions!
Thanks Nancy.
Because CBT and GET trials have been sooo dominant in ME/CFS – dozens of studies have explored their effectiveness – while so few other clinical trials have been done; I can count on the fingers of one hand the number of studies that have looked at a treatment twice – they have been a real flashpoint. There have been a lot of CBT and exercise trials in FM – an enormous number of exercise trials actually – but since FM has 3 FDA approved drugs they’re not given the kind of prominence in FM as they are in ME/CFS where they are often listed as the only effective treatment.
In short CBT and GET have not gotten the same kind of attention in FM as they have in ME/CFS…Advocacy in general is really lacking from what I can tell in FM actually.
We can use some blogs on the intersection between EDS, FM and ME/CFS if you’re interested 🙂
What a waste of funding!!
Ding Dong the Witch is Dead! We’ve got a list of doctors who are going to get a copy of this!
Kim & Kelly Derrick
I was professional football player when I got CFS. It didnt hit me so badly in the beginning but I had to stop my career immediately. I really like walking but I have to stay in my energy limit because if not I got immediately PEM and crash. I know already my limits so I dont crash often – I walk around 1 hour every day to dont be decondition. But even if I dont feel bad after 1 hour, my muscles are completly week, I feel every day small pain especially in my legs muscles because of lactat accumultion. Why is there lactat accumulation if I walk every day the same distance. The GET theory doesnt fit. I am absolutly sure if my CFS would stop next day in 1 week I would be able to run 10 kilometers.
Great example…
Very well-written and helpful article to summarize the most common sources of info that health professionals in the US tend to use. Great idea!
Of note is the atrociously inaccurate info provided about ME/CFS via American Family Physician to our primary care providers. I guess we need to understand why our PCs are responding to PWMEs they way they do!! Geesh.
Agreed! The American Family Physician of all places….Geesh!
Best point ever seen in one of your articles on how the European government has done what it has done.
We desparetly need these trials to start soon to many years lost.
Indeed! We have actually had quite a few trials that have had positive effects but they are one-off, small trials that in now way can compare to the dozens of CBT/GET trials some of which cost millions of dollars and contained hundreds of patients.
Even after all that even the Cochrane reports do say all that much positive about them.
Enough is enough
Thanks for a great article. I am a fan of CBT for what it has done to help me with anxiety relating to overthinking, expecting and trying to plan for the worst that might happen and to stop negative self-punishing talk going on in my head. Dealing with this anxiety has helped my ME/CFS in so far as lessening mental stress that makes my general condition worse. BUT, this is where the relationship between the two stops.
Last year I got the flu. It made my ME/CFS worse. I took flu tablets. It helped my flu and thus inadvertantly my ME/CFS. Does it translate that flu tablets should be a ‘go to’ treatment for ME/CFS? Of course not.
And GET, well did this ever add up to anyone who has experienced ME/CFS?
Made me so angry to read in your article what some of these sites are STILL informing and recommending to medical professionals. I so hope the debunking of the Pace trial outcomes get as much, no wait, MORE attention than the Pace trial got. So much damage to so many.
Thanks for your balanced viewpoint Krista 🙂
Tuha, it may not be lactic accumulation. Metabolites clear rather quickly, but the immune response to exercise lasts several days. It could be the sensitivity to the inflammation from the accumulated immune response causing your constant muscle pain. (My muscle ache goes away in a few days if I reduce or stop walking). Here is an article about the exercise effect and my blog linking it to CFS:
http://breakingmuscle.com/health-medicine/whats-happening-in-your-blood-after-a-workout
I discussed the implication of this to CFS patients in my blog. As for GET, yeah I agree with everybody that it does not work. I should know, I’ve been walking for 8 years. I’m still walking, but only because it improves my sleep and mood.
“One might assume that the more rigorous reports might be authoritative in the field. The AHRQ is highly respected but because the report was not published in the medical literature it will not get as much spread as it would otherwise.”
Are you talking about the initial report or this addendum? I believe the initial report was published in the Annals of Internal Medicine journal: http://annals.org/article.aspx?articleid=2322801
I would think they would also publish this addendum in the journal as well.
Looks like my link didn’t work. http://dx.doi.org/10.7326/M15-0114
I have requested AHRQ when they will update the published article in Annals with this Addendum. Waiting for a reply and will let the community know when I hear.
I also want to add that while I led this effort, there were a number of other people involved along the way, particularly Jennie Spotila. We raised the problems with this review when the protocol was first issued and then again when the draft report was issued. Tuller’s articles also really helped.
Thanks Mary.
I want to take this opportunity to note Mary’s longstanding and in depth analysis of the definition issues facing ME/CFS. No patient advocates have examined this issue so closely.
🙂 Well that’s good news. I searched for it using AHRQ and chronic fatigue syndrome and got nothing. I’m glad it got published (and will amend the blog);
Oh for a well-designed, large Ampligen trial! I do believe finding a treatment for the biological illness(es) may be the most effective way to finally banish this travesty of CBT/GET. Thanks for the great reporting once again, Cort!
Agreed….It’s about time for that Ampligen trial!
Cort, has there been any report yet on the NIH study performed
this summer re CFS? I’ve not seen anything yet. Also what happened to Dr. Davis’ study report submission to JAMA? I have not seen anything reported on his findings.I’m chomping at the bit for studies to send to my PCP & other drs in my community who are extremely ill-informed re CFS/ME and have thus treated me with the CBT “blow off” attitude. As always, you are a vital resource to the CFS/ME community on how to stay informed re the latest news & studies. Immeasurable gratitude for you for all your hard work!
Lynne
I should hear from the NIH any day on the progress getting more funding.
A Naviaux / Ron Davis paper is about to hit the streets so to speak. It’s quite exciting 🙂
Thanks.
I am one of I think few mental illness sufferers and advocates who is also diagnosed with CFS and “advocates” (does being open about having cfs and pariticpating in petitions and patient forums count?)- certain things disqualify me from being included in CFS studies here in the US- and that is good I think, though in the future I would be really pleased to see people with some of my comorbidities included and tested seperately…
For example, do we know if all of these “acceptable” trials specifically excluded anyone with a diagnoses or symptoms of depression (major or dysthymia) which existed before they developed CFS symptoms? I would like to see a study specifically which measures CFS with depression comorbidity, against CFS without depression comorbidity, against people without either.
Yes it would be nice to see a baseline, because I am of the stand point that good therapy can help *almost* anyone’s mood, energy, and overall health.
I am also of the perspective that bad or even mediocre therapy can make anyone’s mental and or physical health worse.
I do not consider CBT good therapy on its own. It depends on how it is applied, by whom, the relationship between the clinician and patient, the level of cooperation, additional treatments, outside circumstances, medications, other care, new puppies, other diagnoses, and the phases of the moon.
In mental health CBT is and has been for me, a fluff term, for years. It means pretty much nothing to me. I know what it is supposed to be. And I know that is not what it looks like in the real world. And I also know sending people to CBT certified counsellors, etc. unclogs doctors offices when it comes to physical illness too.
Every year we see millions poured into applying CBT to every mental illness ever, now we are seeing it happen with physical illnesses too. We see the same exact pattern with SSRIs. Many of these studies consistently demonstrate positive results. To me they are all questionable, at best, and harmful at worst.
Is CBT likely to make your mental illness symptoms, pain, or fatigue WORSE… Probably not. So pursuing it so fiercely for every ill is actually a symptom of a highly conservative path in medicine. But the harm comes to the patients who do not receive benefit and now have to deal with their fall out -possibly alone, another doctor on the list of people who didn’t help or made you feel worse, and the impression to society (and our doctors and families) that what is wrong with us is a behavioral CHOICE that could be changed within 12 hours of theraputic sessions.
Additionally I can’t even get my own doctors to agree on a definition of fatigue, so I am not sure how that all gets worked out. My one doc still thinks I am “sleepy” even though I tell her that is not the case.
Now I will admit I do not have a whole lot of knowledge about the patient criterias and exclusions beyond Oxford/Fukuda/ICC-CCC (ranked in degrees of strictness and usefulness for many of us here).
But I absolutely cannot get over this:
“The P2P report stated that the Oxford definition was so broad – only requiring that unexplained fatigue be present – that any study using it was likely to include people who did not have ME/CFS”
If you have ever spent any amount of time researching chronic and even many acute illnesses you will find an overall pattern…
Generalized Fatigue is pretty much a symptom of every single chronic or reoccuring disease or syndrome known to man. It would be easier to make a list of diseases that DO NOT cause fatigue in the majority of people. Probably 80%+ of people with a chronic illness, no sources just my estimate, have reoccuring or chronic fatigue (not the syndrome, just the symptom).
If you are using “fatigue” as your only inclusion in a study… You pretty much are spending a lot of millions… On absolutely nothing useful. Even with a known diagnoses which has fatigue as a symptom, it still can be considered unexplained because we really do not know why exactly we get fatigue a lot of the time, it just is.
And that unexplained fatigue or idiopathic fatigue successes are somehow supposed to help people with CFS is a stretch for me. Sure if something works on one type of fatigue- why not try it on another- but repetitively spending millions on such in the hopes you are going to get a good result is pretty silly, especially if the improvement in idiopathic fatigue was MINOR anyway. If you are gonna try, actually try, don’t throw money at something that won’t even be useful.
Its a little saying you are trying to cure depression… Then giving candy to someone with the temporary sads and seeing that it cheered them up a little. But then you start offering that as the only effective treatment options to people with active chronic major depression disorder and not considering any other treatments as useful. But the thing is, candy makes not sad people happy too. But it probably isn’t good for people with diabetes sad or not.
Thanks Shy
I too have heard that CBT has been over promoted in depression.
TMany studies have accounted for depression; i.e. when they compare the results of people with ME/CFS with depression to people with ME/cFS without depression the results usually don’t change; i.e. depression doesn’t seem to make much of a difference.
Dr. Natelson, however, has done several studies which suggest that people with ME/CFS who are depressed actually have fewer neurological abnormalities than people with ME/CFS who are not depressed (go figure!). I believe that he’s continuining his work in this area.
I’m a bit behind the wave on this thread, just catching up from here in the UK (sorry folks that we Fukada’d things up for sufferers).
The recent release of the PACE trial data into the public domain is an exciting development and hopefully, together with other initiatives happening your side of the pond, will herald the end of the UK/European psychiatric stranglehold on progress.
Sufferers have always known that GET/CBT as ‘treatments’ constitutes abuse, something worse than ineffective. I believe that this is a shame, since physical activity and a positive attitude are beneficial to everyone. If the message had been (and now it should be) that ‘look folks, physical activity ain’t gonna make you well, in fact if you go beyond your own limit of tolerance, which may be very low, it may well make you more ill ,so be very cautious, use a HR monitor or whatever works for you…listen to your body constantly…ironically it’s called pacing (were they taking the p1$$ with the name of the trial???). Pacing means that the patient themselves decides on every facet of the physical activity – timing, type, intensity, duration – when, what, how hard, how long.
After 25 years with ME, I think I’ve established through a study with a sample size of one and without a great deal of methodology and statistical analysis (although I do have quite a lot of data), that it is possible (at least for all the people in this study) for an ME sufferer to achieve physiological adaptations to imposed physical demands. The caveats are that it can be risky, and that there needs to be acceptance of a trade-off between wellness and fitness…i.e. get fitter and reduce other disease risks, but accept feeling more ill more of the time in the short term (a tough call).
This is the nature of the messaging that I would personally advocate now that the London Fatigue Empire is starting to crumble. It will be interesting to see whether they now walk quietly away from their demise or mount a desperate defence. Up to now they have been able to make outrageously ridiculous statements without any comeback, but surely any credibility they have fabricated over the years is now not sustainable.
Well done to all the advocates (and others) noted here, and yes, bring on the biological trials with neither smoke nor mirrors.
Physical activity and a positive attitude are beneficial to everyone. And CBT always helpful to reduce fatigue or produce global improvement in a person that you have wisely discussed in this blog.
I have read so many articles regarding the blogger lovers except this piece of
writing is actually a pleasant post, keep it up.