Petition: S4ME 2023 - Cochrane: Withdraw the harmful 2019 Exercise therapy for CFS review

Joan Crawford · Feb 22, 2024

NelliePledge said: ↑

Hi @Joan Crawford. We did contact a lot of UK groups through ME Local which is included in signatory list not sure if that includes Chester? But we’ve also got groups that signed up in their own name. Happy to add Chester to the list based on your request nothing further needed.
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Fab thanks

The name is:

Chester MESH self help group

Many thanks
Joan

NelliePledge · Feb 22, 2024

Thanks @Joan Crawford ive added Chester to the signatory list.

Andy · Mar 4, 2024

Current total is 10,563

https://www.change.org/p/cochrane-withdraw-the-harmful-2019-exercise-therapy-for-cfs-review

Caroline Struthers · Mar 7, 2024

Here's the latest between me and Cochrane.

https://www.s4me.info/threads/cochr...a-bastians-talkpage.36153/page-14#post-519865

Andy · Mar 16, 2024

Current total is 10,578

https://www.change.org/p/cochrane-withdraw-the-harmful-2019-exercise-therapy-for-cfs-review

Trish · Mar 18, 2024

The committee has sent a new letter to key people at Cochrane, posted on the letter thread:
https://www.s4me.info/threads/s4me-...rcise-therapy-review.34973/page-2#post-521800
It's quite long, so I'll summarise it in the next post.

Science For ME said: ↑

On 17th March 2024 the Science for ME Committee sent the following:

To
Jordi Pardo Pardo - Interim Chair of the Cochrane Governing Board
Karla Soares-Weisser, Cochrane Editor in Chief
Vanessa Jordan, Chair - Cochrane's Conflict of Interest Committee

Subject: Exercise therapy for ME/CFS

Dear Jordi Pardo Pardo, Karla Soares-Weisser and Vanessa Jordan,

Six months ago we wrote to the Editor-in-Chief (August 2023) regarding the 2019 Cochrane review: Exercise therapy for chronic fatigue syndrome by Larun et al. (Larun, 2019) Since then no progress has been made on the new review and older versions remain. It is clear that our request that the new review be published within a year of our initial letter will not be achieved.

We repeat our great concern that while the 2019 review is in place and continuing to be cited, interventions are being promoted that have been shown not only as ineffective (Wilshire, 2018), but also to cause serious harm to patients.

We are writing to you today to ask you to reopen consideration of withdrawal of the 2019 review as a matter of urgency, on the grounds of increasing and compelling evidence of harm to both the physical and mental health of patients, as we set out in the following section.

We formally present to the Cochrane board and editors our request, supported now by 70 organisations worldwide, listed below, and 10,500 individuals from 24 countries who have signed our petition, Cochrane: Withdraw the harmful 2019 Exercise therapy for CFS review (Petition, 2023).

Over 500 people have added comments to our petition. Many report that they or their loved ones are suffering serious and lasting deterioration directly attributable to Graded Exercise Therapy (GET). Some people have lost mobility or the ability to work, some need to use a wheelchair. Some have become housebound and even bedridden for years. The petition comments are addressed to Cochrane. We hope you will read them.

We do not think that Cochrane would tolerate such a delay in withdrawing a review relating to a pharmaceutical intervention that had been shown to be ineffective and cause harm. We fail to understand why a behavioural approach, pushing patients to damage themselves, should be treated differently. For very good reasons the harms standard has a lower bar for triggering precautionary action. It does not require the same level of robust evidence as claims of benefit do, only a significant plausible concern, which standard is easily met in this case by available evidence.

Cochrane editors, in going along with the recommendation of exercise therapy on the basis of short term subjective outcomes on unblinded trials, with multiple flaws as spelled out by Tack in 2020 do a disservice to people with ME/CFS and to science. That Larun et al, advised by people with serious conflicts of interest, failed to investigate the validity of harms data in the PACE trial, and failed to follow Cochrane's guidance on seeking wider evidence of adverse events, makes the review unsafe.

We therefore conclude by repeating our request that Cochrane follow its own editorial policy on withdrawing reviews on the basis that:

Following the conclusions of the published review could result in harm to patients or populations of interest.

We trust you will give urgent attention to this serious matter and reach a rapid decision in line with Cochrane's own policy and charitable purpose and in the interests of patient welfare and sound science.

Thank you for your consideration of our request. We would draw your attention to the points below in support of withdrawal of the review.

Yours sincerely,

Trish Davis on behalf of the committee of Science for ME
__________________

Evidence in support of withdrawal

1. Withdrawal of the review is in line with Cochrane's editorial policy

Cochrane Reviews are withdrawn when serious issues with conduct or reporting are identified. The 2019 review meets the conditions for withdrawal of the review on the grounds, both that there are "factual errors in describing one or more included studies that risk misinforming implementation or investment decisions about an intervention" and that "Following the conclusions of the published review could result in harm to patients or populations of interest (other than known adverse effects)."
(Cochrane's editorial policy: Withdrawal of published articles)

2. Cochrane's guidance to reviewers has not been followed

The 2019 review places adverse events in a key position as one of two primary outcomes. However, the reviewers made the narrowest possible interpretation of this, including only data from one trial. This is contrary to the Cochrane handbook which specifies a more detailed analysis of adverse effects in cases such as this where the potential for harm has a major influence on treatment and policy decisions. In such cases it is expected that a bespoke search process will be undertaken that includes a wider selection of sources than that required to identify data on beneficial outcomes. (Cochrane Handbook for reviewers Chapter 19 - Adverse events)

3.The 2019 review failed to properly consider evidence of harms.

The 2019 review did not analyse fully the data on harms of the largest trial, the only one to collect such data, the PACE trial (White et al, 2011). The review relied instead on the PACE researchers’ own analysis and conclusions. Analysis of individual patient data (Vink, 2017) shows very high levels of deterioration in the PACE participants who underwent graded exercise therapy. Yet the PACE trial reported only two serious adverse outcomes in the GET group and Larun et al accepted that conclusion without question. There were also higher drop out rates and deterioration in GET groups than control groups in other trials (Vink, 2017; Vink, 2018).

All analyses, Kindlon (2011 and 2017), Geraghty (2017) and Kirke (2017), of survey data were omitted. Large scale surveys have consistently found deterioration in participants’ health, often reporting being very much worse, after GET even when done under the supervision of specialist therapists. It seems that Larun et al accepted the PACE triallists incorrect claim that survey data showing harms was not based on specialist treatment. (Kirke, 2017)

4. Patients' perceptions of harm should be considered as relevant as patients' perceptions of improvement

GET is justified on the basis that, regardless of a lack of any objective improvement in physical capability, the inducing of a positive change in the patient's perception of their ability to tolerate exertion is a useful outcome. Proponents of GET have accepted patients' subjective reports of, usually short term, improvement as evidence of the success of the treatment. To be consistent, those that hold that view must equally allow that reporting by patients of a seriously negative change in their ability to tolerate exertion while receiving GET is a failure of the treatment. A large number of patients have reported a seriously negative change in their perceived ability to tolerate exertion after GET (Edwards (2021).

5. The harms are considerable

PACE participants who underwent graded exercise therapy showed very high levels of deterioration: of the 160 people in the GET group, all able to complete the 6-minute walk test at the start of the trial, 22 did worse at 52 weeks, and 49 either refused or were not able to do the walk test at 52 weeks. (Vink, 2017)

Surveys and patients' testimony report that harm from GET is common, is severe, and can be long lasting, with some becoming housebound or bedbound for years, suffering pain, severe debility, extreme sensory sensitivities, cognitive dysfunction, orthostatic intolerance and multiple other symptoms affecting many parts of the body. Patients' severity level can go from mild to severe following a short course of therapist led GET.

It is important for decision makers at Cochrane to understand that harm in ME/CFS is not just short term discomfort, nor is it the result of non-expert treatment, as the supporters of exercise therapy contend. Neither is it just relevant to people with severe ME/CFS. Indeed as surveys show, many who start treatment with mild ME/CFS become severe.

6. New evidence of harms supports withdrawal

Since the 2019 review was published, further evidence has become available, including a survey carried out in the UK over three weeks in early 2019 to help inform the NICE evidence review. It reported on over 2000 people's experience of CBT and GET, mostly provided by NHS specialist clinicians since the 2007 NICE guideline recommended these interventions.

With GET on its own, the majority of responders reported not completing the course (61%), of those that started the course 81% reporting worsening of symptoms. Approximately seventy nine percent of people reported no improvement (11.7%) or deterioration (67.1%) in physical health [18.5% minor deterioration, 48.6% major deterioration]. 79% of people reported that GET led to no change (25.5%) or worsening (53% ) of mental health after GET... 86% of responders reported that GET, when combined with CBT, had worsened their symptoms. (OxCATTS, 2019).

The report includes short quotes from patients describing the nature of worsening. Many reported long term deterioration and additional symptoms such as pain that they had not experienced before GET. Severity levels before and after treatment were reported. The percentage with severe ME/CFS increased after GET.

A recent paediatric trial found not only that GET was ineffective, but reported evidence of deterioration in 27% of the participants in the GET group who remained in the study at followup. (Gaunt et al, 2024)

7. Two conflicting paradigms

Cochrane editors should be aware that the supporters of the psychosomatic model of ME/CFS and who are proponents of CBT and exercise therapy for CFS are a minority of the medical profession. GET is based on the unevidenced hypothesis that "CFS/ME is perpetuated by deconditioning, reduced physical strength and altered perception of effort consequent upon reduced physical activity". (PACE GET Manual for Therapists, Bavington, White et al.).

Many other academics and clinicians researching and caring for people with ME/CFS, including psychology professor, Brian Hughes, recognise the failure of the psychosomatic paradigm and the CBT/GET approach to treatment. Far from being a few disgruntled patients and misguided patient organisations opposing these treatments, most scientists currently studying ME/CFS recognise that there are biological factors that make people who experience Post-exertional Malaise (PEM), the core defining feature of ME/CFS, sicker as a direct result of exertion beyond their already very limited capacity. (Keller 2014, Moore 2023). This means that GET is contraindicated for people diagnosed using current diagnostic criteria that require PEM.

8. The harms include effects on patients’ mental health

The harm caused by GET is not simply physical deterioration. GET is based in the psychosomatic paradigm, with the assumption that people can be well if they overcome their fear of activity and over-sensitivity to symptoms. This creates a serious disconnect and a loss of trust between the health professionals and the patients who are not able to improve despite following exercise or activity schedules under the guidance of specialist therapists.

In the survey described above, 53% reported worsening mental health following GET prescribed by UK specialist clinics. (OxCATTS, 2019).

König et al found that a third of the ME/CFS patients in their survey had experienced suicidal thoughts, and that a main factor contributing to suicidal thoughts, reported by 90% of those who had had them, was being told that the disease was only psychosomatic. (König et al)

In a GET trial, Gaunt et al report that there was one hospital admission of a child due to suicidal ideation that the authors acknowledged was possibly due to GET. (Gaunt et al)

9. Biases and conflicts of interest of advisors to the review

There are reasonable concerns that harms may have been underplayed or overlooked because of unbalanced advice to the 2019 Larun et al review.

The Larun authors include Jonathan Price who had a previously stated position on ‘medically unexplained physical symptoms’.

Peter White is listed as an advisor to the review. Both Peter White and Michael Sharpe, a long term departmental colleague of Price, were lead authors on the PACE trial. As well as an obvious interest in defending the trial paper’s disregard of data on harms, White has reputational and financial interests in the supposed safety and efficacy of GET. He has for many years acted as a paid advisor to a reinsurance company in whose interest it is that ME/CFS be classed as psychosomatic and amenable to CBT/GET treatment, as this limits disability payouts. Sharpe and White's conflicts of interest were not declared as they should have been in the consent process for PACE participants. Geraghty, 2017 addresses conflicts of interest and Lubet, 2017 highlights reasons for the particularly high risk of investigator bias in PACE.

The second advisor to the 2019 review, Paul Glasziou, had published papers supporting exercise interventions for ME/CFS (Glasziou, 2019).

There was no one who took part in the review or advised on it who takes a more critical view of GET. There was an obvious lack of openness to the possibility that GET could be ineffective and harmful, and this could plausibly have led to a minimization of the potential for harms.

10. The NICE approach to harms evidence, and the pushback from GET supporters

In October 2021 NICE published a new ME/CFS guideline. The accompanying evidence review included both efficacy and harms data analysis. The conclusion was to recommend against GET. Since publication, clinicians supporting GET, including White, Sharpe and Wessely with their ongoing conflicts of interest, Paul Glasziou, who, along with White, is listed as an advisor to the 2019 Larun review, and Cochrane's Paul Garner, have been conducting a campaign against the NICE findings against GET. However, their claims have been shown to be groundless (Hughes, 2023), (Barry et al, 2024).

In their section on harms data used by NICE, Barry (Barry et al, 2024), explains the importance of evidence reviews including qualitative and survey evidence on harms which were found to be 'by some accounts quite devastating'.
_________________

The letter concluded with the list of 70 organisations supporting our requests to Cochrane.
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Trish · Mar 18, 2024

Summary of the latest S4ME letter to Cochrane:

We mark the fact that it's 6 months since we first wrote to Cochrane and no action has been taken on our requests, and no progress has been made on the new review.

We formally present the petition to Cochrane and encourage them to read the comments on it.

We request that the decision not to withdraw the 2019 Larun review be reopened urgently on the grounds of harm.

We give 10 grounds related to the harms caused by GET for the review to be withdrawn, under these headings:

Evidence in support of withdrawal

1. Withdrawal of the review is in line with Cochrane's editorial policy

2. Cochrane's guidance to reviewers has not been followed

3.The 2019 review failed to properly consider evidence of harms.

4. Patients' perceptions of harm should be considered as relevant as patients' perceptions of improvement

5. The harms are considerable

6. New evidence of harms supports withdrawal

7. Two conflicting paradigms

8. The harms include effects on patients’ mental health

9. Biases and conflicts of interest of advisors to the review

10. The NICE approach to harms evidence, and the pushback from GET supporters
_________________

The letter is signed by me and the committee. Although I drafted and edited the letter, several committee members and staff helped with additional suggestions and improvements, for which I thank them.

Peter Trewhitt · Mar 18, 2024

Trish said: ↑

Summary of the latest S4ME letter to Cochrane:

We mark the fact that it's 6 months since we first wrote to Cochrane and no action has been taken on our requests, and no progress has been made on the new review.

We formally present the petition to Cochrane and encourage them to read the comments on it.

We request that the decision not to withdraw the 2019 Larun review be reopened urgently on the grounds of harm.

We give 10 grounds related to the harms caused by GET for the review to be withdrawn, under these headings:

Evidence in support of withdrawal

1. Withdrawal of the review is in line with Cochrane's editorial policy

2. Cochrane's guidance to reviewers has not been followed

3.The 2019 review failed to properly consider evidence of harms.

4. Patients' perceptions of harm should be considered as relevant as patients' perceptions of improvement

5. The harms are considerable

6. New evidence of harms supports withdrawal

7. Two conflicting paradigms

8. The harms include effects on patients’ mental health

9. Biases and conflicts of interest of advisors to the review

10. The NICE approach to harms evidence, and the pushback from GET supporters
_________________

The letter is signed by me and the committee. Although I drafted and edited the letter, several committee members and staff helped with additional suggestions and improvements, for which I thank them.
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Thank you @Trish and all involved for all the work gone into this letter. It is hard to see how anyone with a modicum of sense could continue to ignore these points.

One can only conclude that Cochrane management are now deliberately avoiding any meaningful consideration of these issues, placing their reliance on a small number of pro GET activists, some with very close links to Cochrane, over and above any pretence of scientific balance.

Caroline Struthers · Mar 18, 2024

Peter Trewhitt said: ↑

anyone with a modicum of sense
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seemingly in short supply @ Cochrane Towers!

Hutan · Mar 21, 2024

A update about our most recent letter to Cochrane has been posted on the petition - the update looks a lot like Trish's summary above.

If you haven't had a look at the petition yet, please do. Here's the link: https://chng.it/xwQ9bGgcdL

SNT Gatchaman · Mar 23, 2024

Related to ongoing harms from uncorrected guidance: the UK Covid enquiry is hearing from families of those with eg intellectual disabilities who were denied ICU care and died in the early stages of the pandemic. Thousands of disabled people died after ‘Covid treatment withheld’, inquiry to probe (iNews)

On 20 March 2020, as the Covid crisis was accelerating in hospitals, the NHS watchdog NICE (the National Institute for Health and Care Excellence) issued guidance for trusts and hospitals advising them to apply a “clinical frailty scale” to decide whether patients should be admitted to intensive care.

Older and more frail patients were viewed as being less likely to survive even with critical care treatment.

But according to the learning disability charity Mencap, the original NICE guidance also suggested that those who could not do everyday tasks like cooking, managing money and personal care independently – which are common for people with a learning disability, but who might be otherwise healthy – would be considered frail and as a result might not receive intensive care treatment.
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Mencap complained to NICE and the watchdog revised its guidance in April 2020 to “make clear that the clinical frailty scale should never be used to assess patients aged under 65 or patients of any age with stable long-term disabilities, for example cerebral palsy, learning disabilities or autism”, the charity said.

But in a report published later in 2020, Mencap said: “The original NICE guidance had ongoing damaging consequences.

“By the time clarification to the Clinical Frailty Scale was sent out, it came to Mencap’s attention that many perfectly healthy individuals received letters from their GPs recommending they think carefully about whether they would want resuscitation if they went into hospital or would even want to be treated in hospital at all, should they get Covid-19.”
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Andy · Mar 24, 2024

Current total is 10,598

https://www.change.org/p/cochrane-withdraw-the-harmful-2019-exercise-therapy-for-cfs-review

Maat · Mar 25, 2024

Question:

Does anyone know if NICE issued a statement concerning the possibility of harm resulting from treatment of ME between this specific date parameter?

24.1.2019 - 2.10.2019

The end date being the date Cochrane published the amended version of the Review. Publication of Cochrane Review: ‘Exercise therapy for chronic fatigue syndrome’ | Cochrane

If they did, can someone point me in the direction of a link to it please?

ETA: Also, what is the average timeframe from decision to conduct a review and it's publication?

Peter Trewhitt · Apr 10, 2024

Maat said: ↑

ETA: Also, what is the average timeframe from decision to conduct a review and it's publication?
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There is a recent research paper that looks at this question that has a thread here. I will try to find it, but I have specific problems in coping with how larger amounts of information are structured.

[added - I found the link more easily than expected - https://www.s4me.info/threads/half-...after-the-protocol-2020-andersen-et-al.37474/ “Half of Cochrane reviews were published more than 2 years after the protocol, 2020, Andersen et al.” ]

Peter Trewhitt · Apr 10, 2024

Peter Trewhitt said: ↑

There is a recent research paper that looks at this question that has a thread here. I will try to find it, but I have specific problems in coping with how larger amounts of information are structured.

[added - I found the link more easily than expected - https://www.s4me.info/threads/half-...after-the-protocol-2020-andersen-et-al.37474/ “Half of Cochrane reviews were published more than 2 years after the protocol, 2020, Andersen et al.” ]
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Sorry, although the thread here was recent, the article itself is from 2020. See https://www.jclinepi.com/article/S0895-4356(20)30124-4/abstract . I haven’t yet found access to the full text that is not behind a paywall.

Peter Trewhitt · Apr 10, 2024

Just found a potentially relevant article:

Use of inactive Cochrane reviews in academia: A citation analysis

Open access

Published: 12 April 2023 Volume 128, pages 2923–2934, (2023)

Bodil Hoffmeyer,

Siv Fonnes,

Kristoffer Andresen &

Jacob Rosenberg

see https://link.springer.com/article/10.1007/s11192-023-04691-9

From Abstract

In 2020, 41% of all citations of Cochrane reviews, were of reviews that had not been updated for more than 5.5. years. 5 years after last update, Cochrane reviews were on average cited 8.6 times per year. Twenty-five percent of Cochrane reviews were still cited 10 years after last update and were on average cited 4.3 times in the 10th year. None of the most recent citations of the 20 most outdated reviews indicated directly that the review was out of date. Cochrane reviews continued to be cited even though they were not being updated. This could pose a problem if they do not represent the most up-to-date evidence, as it may lead to the distribution of outdated evidence or misinformation.
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Peter Trewhitt · Apr 10, 2024

Also from 2021:

Most Cochrane reviews have not been updated for more than 5 years.
Hoffmeyer BD, Andersen MZ, Fonnes S, Rosenberg J

See https://europepmc.org/article/med/34427395

From Abstract

The study included 7931 reviews from the CDSR. The median age of all reviews in the CDSR was 5.3 years. Fifty-five percent were published for the first time between 1996 and February 2015 and 88% of these had been inactive for 5.5 years or more. Among these, 89% were first publication of the review that had never been updated afterward.
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Peter Trewhitt · Apr 10, 2024

I have been pondering Cochrane’s latest response to our communication posted on the 2023 Open Letter to Cochrane thread (https://www.s4me.info/threads/s4me-...e-me-cfs-exercise-therapy-review.34973/page-2)

The following response has been received from Cochrane:

Dear Trish Davis and the Committee of Science for ME international forum,

Thank you for your correspondence. We will include the additional points and references to studies in our review of the issues raised by S4ME in previous correspondence. This thorough process will take some time, and we will get back to you about this in due course.

In the short term, some of the questions will be addressed on the Cochrane project website. We will keep you informed of progress.

Kind regards,

Cochrane Support
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Yet again it has no one individually identified as a signatory, and yet again it commits to no clearly specified action and no specified time scale. Obviously the intent to ‘review the issues raised’ as part of a ‘thorough process’ is commendable, but what will that process involve and at what level will it be undertaken/overseen? When can we reasonably object if nothing happens? The promise of updating the Project Website ‘in the short term’ remains very vague as to timescale, especially given we were informed some months ago that such update was already imminent.

I have from this no idea whether Cochrane intend to take our concerns and formal complaints seriously or if this represents yet further attempt to avoid the substantive issues by prevarication and delay tactics. What is most worrying is that, though there have been some expression of regret about ongoing delays, as far as I have seen there has been no acknowledgment of the vital importance of addressing the potential/likely significant harms arising from any interventions based on the 2019 Exercise Review either directly from Cochrane or via Hilda Bastian.

Trish · Apr 10, 2024

I think the latest reply from Cochrane is little more than an acknowledgement of receipt of our letter, sent simply because their standard automated response to all emails includes a promise of a reply within 3 weeks, so they had to send something now the 3 weeks are up.

Basically it says there will be updates when they get around to it, and there is no timescale for their investigation into our complaints, but it will be long.

It's shameful. You'd think we were complaining our cup if tea wasn't hot enough or a button fell off our jacket, for all the urgency they are showing.

This is about people's health and lives.

We might as well not have bothered.

Ravn · Apr 10, 2024

Trish said: ↑

We might as well not have bothered.
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I suspect the people at Cochrane wished you hadn't bothered either... because their pathetic non-reponses seem to suggest they actually are very much bothered (and are hoping that by delaying long enough they can make it all go away; looks like this will be a contest of who is going to be the most stubborn)

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Petition: S4ME 2023 - Cochrane: Withdraw the harmful 2019 Exercise therapy for CFS review

Joan Crawford Senior Member (Voting Rights)

NelliePledge Moderator Staff Member

Andy Committee Member

Caroline Struthers Senior Member (Voting Rights)

Andy Committee Member

Trish Moderator Staff Member

Trish Moderator Staff Member

Peter Trewhitt Senior Member (Voting Rights)

Caroline Struthers Senior Member (Voting Rights)

Hutan Moderator Staff Member

SNT Gatchaman Senior Member (Voting Rights)

Andy Committee Member

Maat Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Trish Moderator Staff Member

Ravn Senior Member (Voting Rights)

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Petition: S4ME 2023 - Cochrane: Withdraw the harmful 2019 Exercise therapy for CFS review

Joan Crawford Senior Member (Voting Rights)

NelliePledge Moderator Staff Member

Andy Committee Member

Caroline Struthers Senior Member (Voting Rights)

Andy Committee Member

Trish Moderator Staff Member

Trish Moderator Staff Member

Peter Trewhitt Senior Member (Voting Rights)

Caroline Struthers Senior Member (Voting Rights)

Hutan Moderator Staff Member

SNT Gatchaman Senior Member (Voting Rights)

Andy Committee Member

Maat Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Peter Trewhitt Senior Member (Voting Rights)

Trish Moderator Staff Member

Ravn Senior Member (Voting Rights)

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