Opinion Is the RACGP HANDI recommendation of incremental physical activity for CFS/ME harming patients?, 2026, Stallard/Praet/Gupta/Smith

Dolphin

Dolphin

Senior Member (Voting Rights)
AJGP > March > Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome

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Volume 55, Issue 3, March 2026

Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis harming patients?​

Jacqueline Stallard Stephan Praet Sandeep Gupta Angela Smith
doi: 10.31128/AJGP-03-25-7614 | Download article
In April 2024, The Royal Australian College of General Practitioners (RACGP) Handbook of Non-Drug Interventions (HANDI)committee published a guideline: Incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis.1 The HANDI committee claims to recommend interventions that are based on ‘solid evidence’.2 But is this always the case?

Continues at:
www1.racgp.org.au

Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome

The Handbook of Non-Drug interventions (HANDI) is an online formulary of non-drug interventions, enabling GPs to offer to a greater choice of interventions to their patients.
www1.racgp.org.au

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Nightsong said:
A response from the "Chair, Editorial Committee for RACGP Handbook of Non-Drug Interventions" in favour of GET:

Invited response to viewpoint article ‘Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis harming patients?’
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Thinks PACE and Larun’s exercise review were good, but says that surveys about harm are at a high risk of bias so we don’t care about those.
The 2023 NICE guideline retraction was highly controversial and not aligned with research evidence, resulting in members of its writing group resigning. Details of the aberrant interpretation of evidence are outlined elsewhere.5,6
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The attention to detail is worrying. It was 2021, and it wasn’t a retraction - it was an update.
 
Liie said:
Are there published data that show that GET is harmful?
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Maybe the important thing is that there is no evidence showing it's helpful.

Any treatment not supported by evidence might be described as harmful, and is certainly unethical. Even if it didn't make people more ill, it's still a waste of taxpayers' money and patients' and clinicians' time.
 
Does anyone know anything about any of the authors? The names don't ring a bell for me but I don't follow things closely in Australia.

The article gives this information:
Jacqueline Stallard
BSc Hons, GDPSY, Macgregor, ACT

Stephan Praet
MD, PhD, FEBSM, FACSEP, Sports and Exercise Physician, Ochre Health, Bruce, ACT; Adjunct Associate Professor, UCRISE, The University of Canberra, Bruce, ACT

Sandeep Gupta
MBBS, MA, FACNEM, FRACGP, Specialist General Practitioner, Lotus Holistic Medicine, Sunshine Coast, Qld

Angela Smith
BPhty (UQ), GDNR (UWA), APAM, Physiotherapist, Your Place Physio, Charnwood, ACT
 
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Liie said:
Are there published data that show that GET is harmful?
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I think the MAGENTA study is pretty compelling. One young person attempted suicide, and even the paper, which was doing its best to put a positive spin on the treatments, acknowledged that it may have been attributable to GET. I'd have to read the study thread again, but I think there were documented deteriorations and no evidence of overall benefits.

Edit:
Magenta Study thread

The abstract says:
There was weak evidence of a greater risk of deterioration with GET (27%) than with AM (17%; p = 0.069).
..
There was no evidence that GET was more effective or cost-effective than AM in this setting, with very limited improvement in either study group evident by the 6-month or 12-month assessment points.
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Lots of information was not collected/loss to followup.

Edit to add: the comparison treatment was essentially graded activity, so don't get swayed by the insignificant p value in the comparison of deterioration by treatment. Both treatments were unhelpful. People deteriorated in both treatments, people dropped out. We know some people shift activity to the target activity with no overall change in activity levels.
 
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Thread on the RACGP HANDI guide here:
Sly Saint

Thread 'Australia: RACGP: GET for CFS'

Very PACE trial based information.

eg"
Adverse effects
Surveys by patient groups of their members have suggested that GET may be harmful to some people with CFS. However, this finding is believed to be due to inappropriately planned or progressed exercise programs, possibly undertaken independently or under supervision from a person without appropriate experience.

Availability
GET should be supervised by a physiotherapist or exercise therapist, preferably with specific experience and training in applying GET to patients with CFS.

The PACE trial has produced a...
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Dolphin said:
Jacqueline Stallard
BSc Hons, GDPSY, Macgregor, ACT
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She is mentioned in that thread.
 
Kitty said:
Maybe the important thing is that there is no evidence showing it's helpful.
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That's important of course. But it would be interesting to know what the best data about this is. Just because it's interesting and also for advocacy.

I suspect that an important reason for why there often is no deterioration seen in studies of GET is selection bias. People who have a strong feeling that they get worse from exercise are much less likely to choose to participate in a study where they are expected to do exercise. So those studies get participants with no or only a little proper PEM.

Same (but maybe to a smaller degree) goes for studies of CBT.
 
Jonathan Edwards said:
actually it was 'significant' but very slight
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The ongoing issues with the word "significant" allow for massive fudging. It obviously means something very different when referring to "statistically signficant"--which usually gets dropped to just "significant," which makes people think of the common meaning of "significant," which is, well, significant. As we know from the PACE example of improvement in the 6-minute walking test in the GET arm, it was "statisticallly significant" but clinically insignificant.
 
Nightsong said:
A response from the "Chair, Editorial Committee for RACGP Handbook of Non-Drug Interventions" in favour of GET:

Invited response to viewpoint article ‘Is the RACGP HANDI recommendation of incremental physical activity for chronic fatigue syndrome/myalgic encephalomyelitis harming patients?’
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It's ridiculous how lazy this is. Even industry shills with no evidence to back their position do a better job of it, because they know and expect those arguments to be scrutinized. This whole response is pure slop, an insult to our intelligence just as much as the author's.
 
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