#knoop — Public Fediverse posts
Live and recent posts from across the Fediverse tagged #knoop, aggregated by home.social.
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Cette semaine, le réseau thématique CNRS Éducation nous présentera ses travaux réunis au sein d’un ouvrage collectif qui paraîtra prochainement :
🔎 🏫 🎓 « Regards interdisciplinaires sur la recherche en éducation »
🗓️ Vendredi 20 mars 2026 de 9h15 à 17h30
📍 CNRS Site Pouchet et en visioconférencePour y participer, suivez le lien zoom indiqué dans le programme : https://rteducation.sciencesconf.org/?lang=fr
@cnrs @shs @sociology @cnrsshs @EducationRechercheADBS @academia @REA
#language #linguistics #socialsciences #biology #miti #inegality #equals #education #sociology #geography #research #collaboration #pedagogy #numerique #ruralité
#SFL #CNRSeditions #Watorek #Borst #Vibert #Gaille #Bodolec #Etxepare #Poulain #Assaiante #Knoop #Gacoin #Vallet #Farrer #Bara #Caro #Goudeau #Buisson #Liquete #Behra #Filiod #CairoCrocco #Clerc #Mascret #Delarue #Gardes #Vors #Allouch #Sallandre #Goudeau #Tenret -
Cette semaine, le réseau thématique CNRS Éducation nous présentera ses travaux réunis au sein d’un ouvrage collectif qui paraîtra prochainement :
🔎 🏫 🎓 « Regards interdisciplinaires sur la recherche en éducation »
🗓️ Vendredi 20 mars 2026 de 9h15 à 17h30
📍 CNRS Site Pouchet et en visioconférencePour y participer, suivez le lien zoom indiqué dans le programme : https://rteducation.sciencesconf.org/?lang=fr
@cnrs @shs @sociology @cnrsshs @EducationRechercheADBS @academia @REA
#language #linguistics #socialsciences #biology #miti #inegality #equals #education #sociology #geography #research #collaboration #pedagogy #numerique #ruralité
#SFL #CNRSeditions #Watorek #Borst #Vibert #Gaille #Bodolec #Etxepare #Poulain #Assaiante #Knoop #Gacoin #Vallet #Farrer #Bara #Caro #Goudeau #Buisson #Liquete #Behra #Filiod #CairoCrocco #Clerc #Mascret #Delarue #Gardes #Vors #Allouch #Sallandre #Goudeau #Tenret -
Cette semaine, le réseau thématique CNRS Éducation nous présentera ses travaux réunis au sein d’un ouvrage collectif qui paraîtra prochainement :
🔎 🏫 🎓 « Regards interdisciplinaires sur la recherche en éducation »
🗓️ Vendredi 20 mars 2026 de 9h15 à 17h30
📍 CNRS Site Pouchet et en visioconférencePour y participer, suivez le lien zoom indiqué dans le programme : https://rteducation.sciencesconf.org/?lang=fr
@cnrs @shs @sociology @cnrsshs @EducationRechercheADBS @academia @REA
#language #linguistics #socialsciences #biology #miti #inegality #equals #education #sociology #geography #research #collaboration #pedagogy #numerique #ruralité
#SFL #CNRSeditions #Watorek #Borst #Vibert #Gaille #Bodolec #Etxepare #Poulain #Assaiante #Knoop #Gacoin #Vallet #Farrer #Bara #Caro #Goudeau #Buisson #Liquete #Behra #Filiod #CairoCrocco #Clerc #Mascret #Delarue #Gardes #Vors #Allouch #Sallandre #Goudeau #Tenret -
Cette semaine, le réseau thématique CNRS Éducation nous présentera ses travaux réunis au sein d’un ouvrage collectif qui paraîtra prochainement :
🔎 🏫 🎓 « Regards interdisciplinaires sur la recherche en éducation »
🗓️ Vendredi 20 mars 2026 de 9h15 à 17h30
📍 CNRS Site Pouchet et en visioconférencePour y participer, suivez le lien zoom indiqué dans le programme : https://rteducation.sciencesconf.org/?lang=fr
@cnrs @shs @sociology @cnrsshs @EducationRechercheADBS @academia @REA
#language #linguistics #socialsciences #biology #miti #inegality #equals #education #sociology #geography #research #collaboration #pedagogy #numerique #ruralité
#SFL #CNRSeditions #Watorek #Borst #Vibert #Gaille #Bodolec #Etxepare #Poulain #Assaiante #Knoop #Gacoin #Vallet #Farrer #Bara #Caro #Goudeau #Buisson #Liquete #Behra #Filiod #CairoCrocco #Clerc #Mascret #Delarue #Gardes #Vors #Allouch #Sallandre #Goudeau #Tenret -
Cette semaine, le réseau thématique CNRS Éducation nous présentera ses travaux réunis au sein d’un ouvrage collectif qui paraîtra prochainement :
🔎 🏫 🎓 « Regards interdisciplinaires sur la recherche en éducation »
🗓️ Vendredi 20 mars 2026 de 9h15 à 17h30
📍 CNRS Site Pouchet et en visioconférencePour y participer, suivez le lien zoom indiqué dans le programme : https://rteducation.sciencesconf.org/?lang=fr
@cnrs @shs @sociology @cnrsshs @EducationRechercheADBS @academia @REA
#language #linguistics #socialsciences #biology #miti #inegality #equals #education #sociology #geography #research #collaboration #pedagogy #numerique #ruralité
#SFL #CNRSeditions #Watorek #Borst #Vibert #Gaille #Bodolec #Etxepare #Poulain #Assaiante #Knoop #Gacoin #Vallet #Farrer #Bara #Caro #Goudeau #Buisson #Liquete #Behra #Filiod #CairoCrocco #Clerc #Mascret #Delarue #Gardes #Vors #Allouch #Sallandre #Goudeau #Tenret -
Dutch Agency Funds CBT Training Program Based on Flawed Long COVID Trial
By David Tuller, DrPH
Here is how bullshit replicates itself in today’s medical world: Conduct a flawed trial, declare success despite serious questions, then develop health policy based on these hyped-up claims.
ZonMW, a major Dutch healthcare funding agency, is supporting a new program led by Professor Hans Knoop, a longtime supporter of the fraudulent PACE trial, to develop “therapist training” for a “post-infection fatigue treatment” dubbed “Fit after an infection.” The training is based on a 2023 study, spearheaded by Professor Knoop and published in Clinical Infectious Diseases, called “Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial.”
The trial was unblinded and relied solely on subjective measures for its claims of benefits—a recipe for an unknown amount of bias. As would be expected with such research, the investigators reported modestly positive results for the primary outcome, self-reported fatigue. But the trial yielded null results for the one objective outcome mentioned in the protocol—amount of physical activity, as measured by monitoring devices worn at the beginning and end of the intervention.
The investigators conveniently left that salient detail out of the published trial report–a choice that (in my view) constitutes a form of research misconduct. Instead, they touted the intervention as a success. When online commenters noted the absence of the physical activity results, the investigators acknowledged the null findings for that measure and then offered ludicrous, “dog ate my data”-type excuses for not having included these data in the paper. As I pointed out on social media, I had just seen a terrific London stage production of Arthur Miller’s The Crucible, and the pro-witchcraft arguments in the play were more credible than the excuses offered by the trial investigators for not having mentioned their null objective outcome results.
The most laughable claim was that level of physical activity bore no relationship to self-reported fatigue. Huh??? Professor Knoop himself has stated otherwise in previous papers, so it is hard to take this assertion seriously. If physical activity were really irrelevant, there would have been no reason to measure it in the first place. Had the physical activity outcome supported the positive subjective results for fatigue, the investigators would undoubtedly have mentioned them.
The new training effort is part of a ZonMW initiative to fund projects that build on previous COVID-19 work funded by the organization. The maximum grant under the program is €50,000, or about $58,000. So it’s a modest sum that, in reality, won’t pay for much.
Here is a description of the new program from the ZonMW site:
“Fatigue is common after COVID-19 and can become chronic in a significant proportion of patients, limiting daily functioning. Cognitive behavioral therapy (CBT) can reduce fatigue, concentration problems, and disability in some of these patients…Because there are few other proven treatments for fatigue after COVID-19, there is a need for CBT. The treatment has been successfully implemented at the Amsterdam UMC, but referral options elsewhere are limited. Fatigue is also common after other infections. Fatigue symptoms after other infections may also be treated with CBT…The aim of the current project is to develop a training program for behavioral therapists to treat chronic fatigue following an infection, such as COVID-19. This can promote the nationwide implementation of CBT for post-infectious fatigue.”
And here is the expected outcome:
“The project will produce an evidence-based, transferable treatment protocol and web-based tool for CBT treatment for fatigue. Both will be made available to participants in the training program. The web tool will be offered to multiple intervention software platforms. Trainers will be appointed to deliver the training program, and the program will be offered to continuing education institutes. Accreditation will be sought from the Dutch Association for Cognitive and Behavioral Therapy (VGCT) and the Federation of Healthcare Psychologists (FGzP), making the training attractive to professionals. The plan is to describe the protocol and background in a Dutch chapter and in a journal for behavioral therapists.”
In other words, based on biased trial with predictable subjective findings that were not supported by the one objective measure, the Netherlands would like to roll out a national treatment infrastructure. Makes sense!
Some patient advocates have protested this project on social media. In response to one such complaint, ZonMW explained that these implementation grants are not peer-reviewed and are awarded to ZonMW-funded investigators who want to put their findings into practice on a first-come, first-serve basis:
“At ZonMw we encourage research results from the COVID‑19 program to find their way into practice. That is why ZonMw opened an implementation‑impulse round for projects that previously received funding. Researchers can turn their earlier findings into concrete products such as training materials, guidelines or educational materials. This is a scheme with a process without reviewers or an assessment committee and without patient involvement. This means that the application is assessed by ZonMw for completeness and whether it meets all the conditions and assessment criteria as set out in the subsidy call. ZonMw assesses applications in order of receipt until the subsidy ceiling is reached.”
ZonMW added:
“We are aware that Cognitive Behavioral Therapy (CBT) for chronic fatigue after COVID‑19 is a sensitive topic. Funding implementation activities after the completion of a research project is a standard procedure for ZonMw. Granting this subsidy application is not a position on what causes post‑COVID or other illnesses.”
It is unwarranted to suggest that patients are “sensitive” about CBT. They are “sensitive” about research, like Professor Knoop’s CBT trial, that is flawed from the start and claims to show what it doesn’t. They have a right to demand that health policy be based on quality trials. Apparently, ZonMW has trouble understanding that concept, at least in this domain.
(View the original post at virology.ws)
#Knoop #Netherlands -
Dutch Agency Funds CBT Training Program Based on Flawed Long COVID Trial
By David Tuller, DrPH
Here is how bullshit replicates itself in today’s medical world: Conduct a flawed trial, declare success despite serious questions, then develop health policy based on these hyped-up claims.
ZonMW, a major Dutch healthcare funding agency, is supporting a new program led by Professor Hans Knoop, a longtime supporter of the fraudulent PACE trial, to develop “therapist training” for a “post-infection fatigue treatment” dubbed “Fit after an infection.” The training is based on a 2023 study, spearheaded by Professor Knoop and published in Clinical Infectious Diseases, called “Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial.”
The trial was unblinded and relied solely on subjective measures for its claims of benefits—a recipe for an unknown amount of bias. As would be expected with such research, the investigators reported modestly positive results for the primary outcome, self-reported fatigue. But the trial yielded null results for the one objective outcome mentioned in the protocol—amount of physical activity, as measured by monitoring devices worn at the beginning and end of the intervention.
The investigators conveniently left that salient detail out of the published trial report–a choice that (in my view) constitutes a form of research misconduct. Instead, they touted the intervention as a success. When online commenters noted the absence of the physical activity results, the investigators acknowledged the null findings for that measure and then offered ludicrous, “dog ate my data”-type excuses for not having included these data in the paper. As I pointed out on social media, I had just seen a terrific London stage production of Arthur Miller’s The Crucible, and the pro-witchcraft arguments in the play were more credible than the excuses offered by the trial investigators for not having mentioned their null objective outcome results.
The most laughable claim was that level of physical activity bore no relationship to self-reported fatigue. Huh??? Professor Knoop himself has stated otherwise in previous papers, so it is hard to take this assertion seriously. If physical activity were really irrelevant, there would have been no reason to measure it in the first place. Had the physical activity outcome supported the positive subjective results for fatigue, the investigators would undoubtedly have mentioned them.
The new training effort is part of a ZonMW initiative to fund projects that build on previous COVID-19 work funded by the organization. The maximum grant under the program is €50,000, or about $58,000. So it’s a modest sum that, in reality, won’t pay for much.
Here is a description of the new program from the ZonMW site:
“Fatigue is common after COVID-19 and can become chronic in a significant proportion of patients, limiting daily functioning. Cognitive behavioral therapy (CBT) can reduce fatigue, concentration problems, and disability in some of these patients…Because there are few other proven treatments for fatigue after COVID-19, there is a need for CBT. The treatment has been successfully implemented at the Amsterdam UMC, but referral options elsewhere are limited. Fatigue is also common after other infections. Fatigue symptoms after other infections may also be treated with CBT…The aim of the current project is to develop a training program for behavioral therapists to treat chronic fatigue following an infection, such as COVID-19. This can promote the nationwide implementation of CBT for post-infectious fatigue.”
And here is the expected outcome:
“The project will produce an evidence-based, transferable treatment protocol and web-based tool for CBT treatment for fatigue. Both will be made available to participants in the training program. The web tool will be offered to multiple intervention software platforms. Trainers will be appointed to deliver the training program, and the program will be offered to continuing education institutes. Accreditation will be sought from the Dutch Association for Cognitive and Behavioral Therapy (VGCT) and the Federation of Healthcare Psychologists (FGzP), making the training attractive to professionals. The plan is to describe the protocol and background in a Dutch chapter and in a journal for behavioral therapists.”
In other words, based on biased trial with predictable subjective findings that were not supported by the one objective measure, the Netherlands would like to roll out a national treatment infrastructure. Makes sense!
Some patient advocates have protested this project on social media. In response to one such complaint, ZonMW explained that these implementation grants are not peer-reviewed and are awarded to ZonMW-funded investigators who want to put their findings into practice on a first-come, first-serve basis:
“At ZonMw we encourage research results from the COVID‑19 program to find their way into practice. That is why ZonMw opened an implementation‑impulse round for projects that previously received funding. Researchers can turn their earlier findings into concrete products such as training materials, guidelines or educational materials. This is a scheme with a process without reviewers or an assessment committee and without patient involvement. This means that the application is assessed by ZonMw for completeness and whether it meets all the conditions and assessment criteria as set out in the subsidy call. ZonMw assesses applications in order of receipt until the subsidy ceiling is reached.”
ZonMW added:
“We are aware that Cognitive Behavioral Therapy (CBT) for chronic fatigue after COVID‑19 is a sensitive topic. Funding implementation activities after the completion of a research project is a standard procedure for ZonMw. Granting this subsidy application is not a position on what causes post‑COVID or other illnesses.”
It is unwarranted to suggest that patients are “sensitive” about CBT. They are “sensitive” about research, like Professor Knoop’s CBT trial, that is flawed from the start and claims to show what it doesn’t. They have a right to demand that health policy be based on quality trials. Apparently, ZonMW has trouble understanding that concept, at least in this domain.
(View the original post at virology.ws)
#Knoop #Netherlands -
Dutch Agency Funds CBT Training Program Based on Flawed Long COVID Trial
By David Tuller, DrPH
Here is how bullshit replicates itself in today’s medical world: Conduct a flawed trial, declare success despite serious questions, then develop health policy based on these hyped-up claims.
ZonMW, a major Dutch healthcare funding agency, is supporting a new program led by Professor Hans Knoop, a longtime supporter of the fraudulent PACE trial, to develop “therapist training” for a “post-infection fatigue treatment” dubbed “Fit after an infection.” The training is based on a 2023 study, spearheaded by Professor Knoop and published in Clinical Infectious Diseases, called “Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial.”
The trial was unblinded and relied solely on subjective measures for its claims of benefits—a recipe for an unknown amount of bias. As would be expected with such research, the investigators reported modestly positive results for the primary outcome, self-reported fatigue. But the trial yielded null results for the one objective outcome mentioned in the protocol—amount of physical activity, as measured by monitoring devices worn at the beginning and end of the intervention.
The investigators conveniently left that salient detail out of the published trial report–a choice that (in my view) constitutes a form of research misconduct. Instead, they touted the intervention as a success. When online commenters noted the absence of the physical activity results, the investigators acknowledged the null findings for that measure and then offered ludicrous, “dog ate my data”-type excuses for not having included these data in the paper. As I pointed out on social media, I had just seen a terrific London stage production of Arthur Miller’s The Crucible, and the pro-witchcraft arguments in the play were more credible than the excuses offered by the trial investigators for not having mentioned their null objective outcome results.
The most laughable claim was that level of physical activity bore no relationship to self-reported fatigue. Huh??? Professor Knoop himself has stated otherwise in previous papers, so it is hard to take this assertion seriously. If physical activity were really irrelevant, there would have been no reason to measure it in the first place. Had the physical activity outcome supported the positive subjective results for fatigue, the investigators would undoubtedly have mentioned them.
The new training effort is part of a ZonMW initiative to fund projects that build on previous COVID-19 work funded by the organization. The maximum grant under the program is €50,000, or about $58,000. So it’s a modest sum that, in reality, won’t pay for much.
Here is a description of the new program from the ZonMW site:
“Fatigue is common after COVID-19 and can become chronic in a significant proportion of patients, limiting daily functioning. Cognitive behavioral therapy (CBT) can reduce fatigue, concentration problems, and disability in some of these patients…Because there are few other proven treatments for fatigue after COVID-19, there is a need for CBT. The treatment has been successfully implemented at the Amsterdam UMC, but referral options elsewhere are limited. Fatigue is also common after other infections. Fatigue symptoms after other infections may also be treated with CBT…The aim of the current project is to develop a training program for behavioral therapists to treat chronic fatigue following an infection, such as COVID-19. This can promote the nationwide implementation of CBT for post-infectious fatigue.”
And here is the expected outcome:
“The project will produce an evidence-based, transferable treatment protocol and web-based tool for CBT treatment for fatigue. Both will be made available to participants in the training program. The web tool will be offered to multiple intervention software platforms. Trainers will be appointed to deliver the training program, and the program will be offered to continuing education institutes. Accreditation will be sought from the Dutch Association for Cognitive and Behavioral Therapy (VGCT) and the Federation of Healthcare Psychologists (FGzP), making the training attractive to professionals. The plan is to describe the protocol and background in a Dutch chapter and in a journal for behavioral therapists.”
In other words, based on biased trial with predictable subjective findings that were not supported by the one objective measure, the Netherlands would like to roll out a national treatment infrastructure. Makes sense!
Some patient advocates have protested this project on social media. In response to one such complaint, ZonMW explained that these implementation grants are not peer-reviewed and are awarded to ZonMW-funded investigators who want to put their findings into practice on a first-come, first-serve basis:
“At ZonMw we encourage research results from the COVID‑19 program to find their way into practice. That is why ZonMw opened an implementation‑impulse round for projects that previously received funding. Researchers can turn their earlier findings into concrete products such as training materials, guidelines or educational materials. This is a scheme with a process without reviewers or an assessment committee and without patient involvement. This means that the application is assessed by ZonMw for completeness and whether it meets all the conditions and assessment criteria as set out in the subsidy call. ZonMw assesses applications in order of receipt until the subsidy ceiling is reached.”
ZonMW added:
“We are aware that Cognitive Behavioral Therapy (CBT) for chronic fatigue after COVID‑19 is a sensitive topic. Funding implementation activities after the completion of a research project is a standard procedure for ZonMw. Granting this subsidy application is not a position on what causes post‑COVID or other illnesses.”
It is unwarranted to suggest that patients are “sensitive” about CBT. They are “sensitive” about research, like Professor Knoop’s CBT trial, that is flawed from the start and claims to show what it doesn’t. They have a right to demand that health policy be based on quality trials. Apparently, ZonMW has trouble understanding that concept, at least in this domain.
(View the original post at virology.ws)
#Knoop #Netherlands -
Dutch Agency Funds CBT Training Program Based on Flawed Long COVID Trial
By David Tuller, DrPH
Here is how bullshit replicates itself in today’s medical world: Conduct a flawed trial, declare success despite serious questions, then develop health policy based on these hyped-up claims.
ZonMW, a major Dutch healthcare funding agency, is supporting a new program led by Professor Hans Knoop, a longtime supporter of the fraudulent PACE trial, to develop “therapist training” for a “post-infection fatigue treatment” dubbed “Fit after an infection.” The training is based on a 2023 study, spearheaded by Professor Knoop and published in Clinical Infectious Diseases, called “Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial.”
The trial was unblinded and relied solely on subjective measures for its claims of benefits—a recipe for an unknown amount of bias. As would be expected with such research, the investigators reported modestly positive results for the primary outcome, self-reported fatigue. But the trial yielded null results for the one objective outcome mentioned in the protocol—amount of physical activity, as measured by monitoring devices worn at the beginning and end of the intervention.
The investigators conveniently left that salient detail out of the published trial report–a choice that (in my view) constitutes a form of research misconduct. Instead, they touted the intervention as a success. When online commenters noted the absence of the physical activity results, the investigators acknowledged the null findings for that measure and then offered ludicrous, “dog ate my data”-type excuses for not having included these data in the paper. As I pointed out on social media, I had just seen a terrific London stage production of Arthur Miller’s The Crucible, and the pro-witchcraft arguments in the play were more credible than the excuses offered by the trial investigators for not having mentioned their null objective outcome results.
The most laughable claim was that level of physical activity bore no relationship to self-reported fatigue. Huh??? Professor Knoop himself has stated otherwise in previous papers, so it is hard to take this assertion seriously. If physical activity were really irrelevant, there would have been no reason to measure it in the first place. Had the physical activity outcome supported the positive subjective results for fatigue, the investigators would undoubtedly have mentioned them.
The new training effort is part of a ZonMW initiative to fund projects that build on previous COVID-19 work funded by the organization. The maximum grant under the program is €50,000, or about $58,000. So it’s a modest sum that, in reality, won’t pay for much.
Here is a description of the new program from the ZonMW site:
“Fatigue is common after COVID-19 and can become chronic in a significant proportion of patients, limiting daily functioning. Cognitive behavioral therapy (CBT) can reduce fatigue, concentration problems, and disability in some of these patients…Because there are few other proven treatments for fatigue after COVID-19, there is a need for CBT. The treatment has been successfully implemented at the Amsterdam UMC, but referral options elsewhere are limited. Fatigue is also common after other infections. Fatigue symptoms after other infections may also be treated with CBT…The aim of the current project is to develop a training program for behavioral therapists to treat chronic fatigue following an infection, such as COVID-19. This can promote the nationwide implementation of CBT for post-infectious fatigue.”
And here is the expected outcome:
“The project will produce an evidence-based, transferable treatment protocol and web-based tool for CBT treatment for fatigue. Both will be made available to participants in the training program. The web tool will be offered to multiple intervention software platforms. Trainers will be appointed to deliver the training program, and the program will be offered to continuing education institutes. Accreditation will be sought from the Dutch Association for Cognitive and Behavioral Therapy (VGCT) and the Federation of Healthcare Psychologists (FGzP), making the training attractive to professionals. The plan is to describe the protocol and background in a Dutch chapter and in a journal for behavioral therapists.”
In other words, based on biased trial with predictable subjective findings that were not supported by the one objective measure, the Netherlands would like to roll out a national treatment infrastructure. Makes sense!
Some patient advocates have protested this project on social media. In response to one such complaint, ZonMW explained that these implementation grants are not peer-reviewed and are awarded to ZonMW-funded investigators who want to put their findings into practice on a first-come, first-serve basis:
“At ZonMw we encourage research results from the COVID‑19 program to find their way into practice. That is why ZonMw opened an implementation‑impulse round for projects that previously received funding. Researchers can turn their earlier findings into concrete products such as training materials, guidelines or educational materials. This is a scheme with a process without reviewers or an assessment committee and without patient involvement. This means that the application is assessed by ZonMw for completeness and whether it meets all the conditions and assessment criteria as set out in the subsidy call. ZonMw assesses applications in order of receipt until the subsidy ceiling is reached.”
ZonMW added:
“We are aware that Cognitive Behavioral Therapy (CBT) for chronic fatigue after COVID‑19 is a sensitive topic. Funding implementation activities after the completion of a research project is a standard procedure for ZonMw. Granting this subsidy application is not a position on what causes post‑COVID or other illnesses.”
It is unwarranted to suggest that patients are “sensitive” about CBT. They are “sensitive” about research, like Professor Knoop’s CBT trial, that is flawed from the start and claims to show what it doesn’t. They have a right to demand that health policy be based on quality trials. Apparently, ZonMW has trouble understanding that concept, at least in this domain.
(View the original post at virology.ws)
#Knoop #Netherlands -
Koning en Knoop: Een Pretige Reis door de Koninkrijken!
Een Reis door de Koninkrijken 🌍
Hallo, lieve kinderen! Ik ben Schildje de Schildpad, en vandaag ga ik jullie meenemen op een bijzondere reis door de tijd. We gaan het hebben over iets heel bijzon...🌞 Leer verder: https://leeralles.nl/koning-en-knoop-een-pretige-reis-door-de-koninkrijken/?feed_id=20815
#DOOR #EEN #KNOOP #KONING #KONINKRIJKE...
https://leeralles.nl/koning-en-knoop-een-pretige-reis-door-de-koninkrijken/?feed_id=20815 -
𝗡𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗳𝗿𝘂𝘀𝘁𝗿𝗮𝘁𝗶𝗲: 𝘇𝗼 𝗵𝗮𝗮𝗹 𝗷𝗲 𝗸𝗲𝗿𝘀𝘁𝘃𝗲𝗿𝗹𝗶𝗰𝗵𝘁𝗶𝗻𝗴 𝗺𝗮𝗸𝗸𝗲𝗹𝗶𝗷𝗸𝗲𝗿 𝘂𝗶𝘁 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Nu Sinterklaas weer terug naar Spanje is, zetten we massaal de kerstboom neer. Toch blijft het ieder jaar weer één grote frustratie: een ondoordringbare hoop aan knopen in je kerstverlichting. Maar waarom raakt kerstverlichting eigenlijk zó snel in de knoop terwijl het...
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𝗡𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗳𝗿𝘂𝘀𝘁𝗿𝗮𝘁𝗶𝗲: 𝘇𝗼 𝗵𝗮𝗮𝗹 𝗷𝗲 𝗸𝗲𝗿𝘀𝘁𝘃𝗲𝗿𝗹𝗶𝗰𝗵𝘁𝗶𝗻𝗴 𝗺𝗮𝗸𝗸𝗲𝗹𝗶𝗷𝗸𝗲𝗿 𝘂𝗶𝘁 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Nu Sinterklaas weer terug naar Spanje is, zetten we massaal de kerstboom neer. Toch blijft het ieder jaar weer één grote frustratie: een ondoordringbare hoop aan knopen in je kerstverlichting. Maar waarom raakt kerstverlichting eigenlijk zó snel in de knoop terwijl het...
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𝗡𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗳𝗿𝘂𝘀𝘁𝗿𝗮𝘁𝗶𝗲: 𝘇𝗼 𝗵𝗮𝗮𝗹 𝗷𝗲 𝗸𝗲𝗿𝘀𝘁𝘃𝗲𝗿𝗹𝗶𝗰𝗵𝘁𝗶𝗻𝗴 𝗺𝗮𝗸𝗸𝗲𝗹𝗶𝗷𝗸𝗲𝗿 𝘂𝗶𝘁 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Nu Sinterklaas weer terug naar Spanje is, zetten we massaal de kerstboom neer. Toch blijft het ieder jaar weer één grote frustratie: een ondoordringbare hoop aan knopen in je kerstverlichting. Maar waarom raakt kerstverlichting eigenlijk zó snel in de knoop terwijl het...
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𝗡𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗳𝗿𝘂𝘀𝘁𝗿𝗮𝘁𝗶𝗲: 𝘇𝗼 𝗵𝗮𝗮𝗹 𝗷𝗲 𝗸𝗲𝗿𝘀𝘁𝘃𝗲𝗿𝗹𝗶𝗰𝗵𝘁𝗶𝗻𝗴 𝗺𝗮𝗸𝗸𝗲𝗹𝗶𝗷𝗸𝗲𝗿 𝘂𝗶𝘁 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Nu Sinterklaas weer terug naar Spanje is, zetten we massaal de kerstboom neer. Toch blijft het ieder jaar weer één grote frustratie: een ondoordringbare hoop aan knopen in je kerstverlichting. Maar waarom raakt kerstverlichting eigenlijk zó snel in de knoop terwijl het...
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𝗡𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗳𝗿𝘂𝘀𝘁𝗿𝗮𝘁𝗶𝗲: 𝘇𝗼 𝗵𝗮𝗮𝗹 𝗷𝗲 𝗸𝗲𝗿𝘀𝘁𝘃𝗲𝗿𝗹𝗶𝗰𝗵𝘁𝗶𝗻𝗴 𝗺𝗮𝗸𝗸𝗲𝗹𝗶𝗷𝗸𝗲𝗿 𝘂𝗶𝘁 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Nu Sinterklaas weer terug naar Spanje is, zetten we massaal de kerstboom neer. Toch blijft het ieder jaar weer één grote frustratie: een ondoordringbare hoop aan knopen in je kerstverlichting. Maar waarom raakt kerstverlichting eigenlijk zó snel in de knoop terwijl het...
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𝗖𝗵𝗮𝗼𝘀 𝗶𝗻 𝗱𝗲 𝘄𝗮𝘀: 𝘇𝗼 𝘇𝗶𝘁 𝗷𝗲 𝗯𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗻𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wasmachine of droger komt? Je bent absoluut niet de enige. Online circuleren allerlei trucjes om te voorkomen dat ja wasgoed in elkaar verstrengelt, maar hoe effectief zijn die? Schoonmaak- en huishoudexpert...
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𝗖𝗵𝗮𝗼𝘀 𝗶𝗻 𝗱𝗲 𝘄𝗮𝘀: 𝘇𝗼 𝘇𝗶𝘁 𝗷𝗲 𝗯𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗻𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wasmachine of droger komt? Je bent absoluut niet de enige. Online circuleren allerlei trucjes om te voorkomen dat ja wasgoed in elkaar verstrengelt, maar hoe effectief zijn die? Schoonmaak- en huishoudexpert...
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𝗖𝗵𝗮𝗼𝘀 𝗶𝗻 𝗱𝗲 𝘄𝗮𝘀: 𝘇𝗼 𝘇𝗶𝘁 𝗷𝗲 𝗯𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗻𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wasmachine of droger komt? Je bent absoluut niet de enige. Online circuleren allerlei trucjes om te voorkomen dat ja wasgoed in elkaar verstrengelt, maar hoe effectief zijn die? Schoonmaak- en huishoudexpert...
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𝗖𝗵𝗮𝗼𝘀 𝗶𝗻 𝗱𝗲 𝘄𝗮𝘀: 𝘇𝗼 𝘇𝗶𝘁 𝗷𝗲 𝗯𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗻𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wasmachine of droger komt? Je bent absoluut niet de enige. Online circuleren allerlei trucjes om te voorkomen dat ja wasgoed in elkaar verstrengelt, maar hoe effectief zijn die? Schoonmaak- en huishoudexpert...
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𝗖𝗵𝗮𝗼𝘀 𝗶𝗻 𝗱𝗲 𝘄𝗮𝘀: 𝘇𝗼 𝘇𝗶𝘁 𝗷𝗲 𝗯𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗻𝗼𝗼𝗶𝘁 𝗺𝗲𝗲𝗿 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wasmachine of droger komt? Je bent absoluut niet de enige. Online circuleren allerlei trucjes om te voorkomen dat ja wasgoed in elkaar verstrengelt, maar hoe effectief zijn die? Schoonmaak- en huishoudexpert...
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𝗚𝗲𝘀𝘁𝗲𝗴𝗴𝗲𝗹 𝗶𝗻 𝗸𝗮𝗯𝗶𝗻𝗲𝘁 𝗼𝘃𝗲𝗿 𝗻𝗶𝗲𝘂𝘄𝗲 𝗡𝗔𝗩𝗢-𝗻𝗼𝗿𝗺: '𝗙𝗹𝗶𝗻𝗸𝗲 𝗽𝗼𝗹𝗶𝘁𝗶𝗲𝗸𝗲 𝗸𝗻𝗼𝗼𝗽'
Het kabinet steggelt over de nieuwe NAVO-norm van 5 procent, waarvan 3,5 procent aan defensie moet worden uitgegeven. Een groei naar 3,5 procent betekent jaarlijks 15 miljard euro extra. Maar hoe moet dat worden betaald? De betrokken ministers zijn het oneens en ook in de coalitie...
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𝗚𝗲𝘀𝘁𝗲𝗴𝗴𝗲𝗹 𝗶𝗻 𝗸𝗮𝗯𝗶𝗻𝗲𝘁 𝗼𝘃𝗲𝗿 𝗻𝗶𝗲𝘂𝘄𝗲 𝗡𝗔𝗩𝗢-𝗻𝗼𝗿𝗺: '𝗙𝗹𝗶𝗻𝗸𝗲 𝗽𝗼𝗹𝗶𝘁𝗶𝗲𝗸𝗲 𝗸𝗻𝗼𝗼𝗽'
Het kabinet steggelt over de nieuwe NAVO-norm van 5 procent, waarvan 3,5 procent aan defensie moet worden uitgegeven. Een groei naar 3,5 procent betekent jaarlijks 15 miljard euro extra. Maar hoe moet dat worden betaald? De betrokken ministers zijn het oneens en ook in de coalitie...
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𝗚𝗲𝘀𝘁𝗲𝗴𝗴𝗲𝗹 𝗶𝗻 𝗸𝗮𝗯𝗶𝗻𝗲𝘁 𝗼𝘃𝗲𝗿 𝗻𝗶𝗲𝘂𝘄𝗲 𝗡𝗔𝗩𝗢-𝗻𝗼𝗿𝗺: '𝗙𝗹𝗶𝗻𝗸𝗲 𝗽𝗼𝗹𝗶𝘁𝗶𝗲𝗸𝗲 𝗸𝗻𝗼𝗼𝗽'
Het kabinet steggelt over de nieuwe NAVO-norm van 5 procent, waarvan 3,5 procent aan defensie moet worden uitgegeven. Een groei naar 3,5 procent betekent jaarlijks 15 miljard euro extra. Maar hoe moet dat worden betaald? De betrokken ministers zijn het oneens en ook in de coalitie...
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𝗚𝗲𝘀𝘁𝗲𝗴𝗴𝗲𝗹 𝗶𝗻 𝗸𝗮𝗯𝗶𝗻𝗲𝘁 𝗼𝘃𝗲𝗿 𝗻𝗶𝗲𝘂𝘄𝗲 𝗡𝗔𝗩𝗢-𝗻𝗼𝗿𝗺: '𝗙𝗹𝗶𝗻𝗸𝗲 𝗽𝗼𝗹𝗶𝘁𝗶𝗲𝗸𝗲 𝗸𝗻𝗼𝗼𝗽'
Het kabinet steggelt over de nieuwe NAVO-norm van 5 procent, waarvan 3,5 procent aan defensie moet worden uitgegeven. Een groei naar 3,5 procent betekent jaarlijks 15 miljard euro extra. Maar hoe moet dat worden betaald? De betrokken ministers zijn het oneens en ook in de coalitie...
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𝗚𝗲𝘀𝘁𝗲𝗴𝗴𝗲𝗹 𝗶𝗻 𝗸𝗮𝗯𝗶𝗻𝗲𝘁 𝗼𝘃𝗲𝗿 𝗻𝗶𝗲𝘂𝘄𝗲 𝗡𝗔𝗩𝗢-𝗻𝗼𝗿𝗺: '𝗙𝗹𝗶𝗻𝗸𝗲 𝗽𝗼𝗹𝗶𝘁𝗶𝗲𝗸𝗲 𝗸𝗻𝗼𝗼𝗽'
Het kabinet steggelt over de nieuwe NAVO-norm van 5 procent, waarvan 3,5 procent aan defensie moet worden uitgegeven. Een groei naar 3,5 procent betekent jaarlijks 15 miljard euro extra. Maar hoe moet dat worden betaald? De betrokken ministers zijn het oneens en ook in de coalitie...
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𝗝𝗼𝗵𝗻𝗻𝘆 𝗱𝗲 𝗠𝗼𝗹 𝗵𝗲𝗲𝗳𝘁 '𝗴𝗲𝗲𝗻 𝗸𝗻𝗼𝗼𝗽 𝗶𝗻 𝗺𝗮𝗮𝗴' 𝘃𝗮𝗻 𝗦𝗽𝗮𝗮𝗻𝘀 𝘃𝗲𝗿𝗵𝗼𝗼𝗿
Johnny de Mol heeft "geen knoop in mijn maag" van het verhoor dat de Spaanse politie hem op 9 december afneemt. Dat vertelde de presentator woensdag in RTL Boulevard. De Mol wordt dan per Zoom-verbinding verhoord over een beschuldiging van mishandeling.
https://www.rtl.nl/boulevard/artikel/5482544/johnny-de-mol-heeft-geen-knoop-maag-van-spaans-verhoor
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𝗝𝗼𝗵𝗻𝗻𝘆 𝗱𝗲 𝗠𝗼𝗹 𝗵𝗲𝗲𝗳𝘁 '𝗴𝗲𝗲𝗻 𝗸𝗻𝗼𝗼𝗽 𝗶𝗻 𝗺𝗮𝗮𝗴' 𝘃𝗮𝗻 𝗦𝗽𝗮𝗮𝗻𝘀 𝘃𝗲𝗿𝗵𝗼𝗼𝗿
Johnny de Mol heeft "geen knoop in mijn maag" van het verhoor dat de Spaanse politie hem op 9 december afneemt. Dat vertelde de presentator woensdag in RTL Boulevard. De Mol wordt dan per Zoom-verbinding verhoord over een beschuldiging van mishandeling.
https://www.rtl.nl/boulevard/artikel/5482544/johnny-de-mol-heeft-geen-knoop-maag-van-spaans-verhoor
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𝗝𝗼𝗵𝗻𝗻𝘆 𝗱𝗲 𝗠𝗼𝗹 𝗵𝗲𝗲𝗳𝘁 '𝗴𝗲𝗲𝗻 𝗸𝗻𝗼𝗼𝗽 𝗶𝗻 𝗺𝗮𝗮𝗴' 𝘃𝗮𝗻 𝗦𝗽𝗮𝗮𝗻𝘀 𝘃𝗲𝗿𝗵𝗼𝗼𝗿
Johnny de Mol heeft "geen knoop in mijn maag" van het verhoor dat de Spaanse politie hem op 9 december afneemt. Dat vertelde de presentator woensdag in RTL Boulevard. De Mol wordt dan per Zoom-verbinding verhoord over een beschuldiging van mishandeling.
https://www.rtl.nl/boulevard/artikel/5482544/johnny-de-mol-heeft-geen-knoop-maag-van-spaans-verhoor
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𝗝𝗼𝗵𝗻𝗻𝘆 𝗱𝗲 𝗠𝗼𝗹 𝗵𝗲𝗲𝗳𝘁 '𝗴𝗲𝗲𝗻 𝗸𝗻𝗼𝗼𝗽 𝗶𝗻 𝗺𝗮𝗮𝗴' 𝘃𝗮𝗻 𝗦𝗽𝗮𝗮𝗻𝘀 𝘃𝗲𝗿𝗵𝗼𝗼𝗿
Johnny de Mol heeft "geen knoop in mijn maag" van het verhoor dat de Spaanse politie hem op 9 december afneemt. Dat vertelde de presentator woensdag in RTL Boulevard. De Mol wordt dan per Zoom-verbinding verhoord over een beschuldiging van mishandeling.
https://www.rtl.nl/boulevard/artikel/5482544/johnny-de-mol-heeft-geen-knoop-maag-van-spaans-verhoor
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𝗝𝗼𝗵𝗻𝗻𝘆 𝗱𝗲 𝗠𝗼𝗹 𝗵𝗲𝗲𝗳𝘁 '𝗴𝗲𝗲𝗻 𝗸𝗻𝗼𝗼𝗽 𝗶𝗻 𝗺𝗮𝗮𝗴' 𝘃𝗮𝗻 𝗦𝗽𝗮𝗮𝗻𝘀 𝘃𝗲𝗿𝗵𝗼𝗼𝗿
Johnny de Mol heeft "geen knoop in mijn maag" van het verhoor dat de Spaanse politie hem op 9 december afneemt. Dat vertelde de presentator woensdag in RTL Boulevard. De Mol wordt dan per Zoom-verbinding verhoord over een beschuldiging van mishandeling.
https://www.rtl.nl/boulevard/artikel/5482544/johnny-de-mol-heeft-geen-knoop-maag-van-spaans-verhoor
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𝗕𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽? 𝗡𝗶𝗲𝘁 𝗺𝗲𝗲𝗿 𝗺𝗲𝘁 𝗱𝗲𝘇𝗲 4 𝘁𝗶𝗽𝘀
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wastrommel komt? Je bent absoluut niet de enige. Door het volgende te doen, heb je er voortaan geen last meer van.
https://www.rtl.nl/wonen/huishouden/artikel/5221799/beddengoed-uit-de-knoop-tips
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𝗕𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽? 𝗡𝗶𝗲𝘁 𝗺𝗲𝗲𝗿 𝗺𝗲𝘁 𝗱𝗲𝘇𝗲 4 𝘁𝗶𝗽𝘀
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wastrommel komt? Je bent absoluut niet de enige. Door het volgende te doen, heb je er voortaan geen last meer van.
https://www.rtl.nl/wonen/huishouden/artikel/5221799/beddengoed-uit-de-knoop-tips
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𝗕𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽? 𝗡𝗶𝗲𝘁 𝗺𝗲𝗲𝗿 𝗺𝗲𝘁 𝗱𝗲𝘇𝗲 4 𝘁𝗶𝗽𝘀
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wastrommel komt? Je bent absoluut niet de enige. Door het volgende te doen, heb je er voortaan geen last meer van.
https://www.rtl.nl/wonen/huishouden/artikel/5221799/beddengoed-uit-de-knoop-tips
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𝗕𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽? 𝗡𝗶𝗲𝘁 𝗺𝗲𝗲𝗿 𝗺𝗲𝘁 𝗱𝗲𝘇𝗲 4 𝘁𝗶𝗽𝘀
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wastrommel komt? Je bent absoluut niet de enige. Door het volgende te doen, heb je er voortaan geen last meer van.
https://www.rtl.nl/wonen/huishouden/artikel/5221799/beddengoed-uit-de-knoop-tips
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𝗕𝗲𝗱𝗱𝗲𝗻𝗴𝗼𝗲𝗱 𝗶𝗻 𝗱𝗲 𝗸𝗻𝗼𝗼𝗽? 𝗡𝗶𝗲𝘁 𝗺𝗲𝗲𝗿 𝗺𝗲𝘁 𝗱𝗲𝘇𝗲 4 𝘁𝗶𝗽𝘀
Raak jij iedere keer weer geïrriteerd als je beddengoed volledig in elkaar gedraaid uit de wastrommel komt? Je bent absoluut niet de enige. Door het volgende te doen, heb je er voortaan geen last meer van.
https://www.rtl.nl/wonen/huishouden/artikel/5221799/beddengoed-uit-de-knoop-tips
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Exodus beim Aufsteiger.
Vorfreude auf die neue Saison des #fcsp im Minus Bereich.
Tja wer hoch fliegt kann halt tief fallen -
Exodus beim Aufsteiger.
Vorfreude auf die neue Saison des #fcsp im Minus Bereich.
Tja wer hoch fliegt kann halt tief fallen -
Exodus beim Aufsteiger.
Vorfreude auf die neue Saison des #fcsp im Minus Bereich.
Tja wer hoch fliegt kann halt tief fallen -
Exodus beim Aufsteiger.
Vorfreude auf die neue Saison des #fcsp im Minus Bereich.
Tja wer hoch fliegt kann halt tief fallen -
Würden wir für einen Torwart Trainer, der gerade seinen Vetrag verlängert hat, auch einen hohen 7 stelligen Betrag bekommen? #knoop #fcsp #brightonandhove
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Würden wir für einen Torwart Trainer, der gerade seinen Vetrag verlängert hat, auch einen hohen 7 stelligen Betrag bekommen? #knoop #fcsp #brightonandhove
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Würden wir für einen Torwart Trainer, der gerade seinen Vetrag verlängert hat, auch einen hohen 7 stelligen Betrag bekommen? #knoop #fcsp #brightonandhove
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Würden wir für einen Torwart Trainer, der gerade seinen Vetrag verlängert hat, auch einen hohen 7 stelligen Betrag bekommen? #knoop #fcsp #brightonandhove
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By David Tuller, DrPH
A survey of more than 1500 patients in the Netherlands with a diagnosis of ME, CFS or ME/CFS rated graded exercise therapy as “the worst” interventions, according to an article on the site of the ME and Disability Support Group, while “explanation and advice about the importance of lying down to prevent worsening of complaints, and about distributing energy and rest (pacing), was most appreciated,” (Translations in this post via Google Translate.)
The survey was conducted as part of the process of developing a set of national ME/CFS management and treatment guidelines. According to the article, these and a few other findings about the impact of the illness were released during a recent meeting in Utrecht at the Knowledge Institute of the Dutch Association of Medical Specialists, which is involved in the guideline development process.
This process is fraught with contention, as was a similar process in the UK. To review, the UK’s National Institute for Health and Care Excellence (NICE) released new guidelines on ME/CFS in 2021, after a multi-year process delayed in part by the pandemic. The new version reversed earlier NICE recommendations for GET and CBT as curative treatments. However, professional medical bodies with vested interests in these discredited interventions have refused to accept the new NICE document. Instead, they have been throwing tantrums in the form of specious journal commentaries that recycled unconvincing and already debunked arguments.
The Dutch survey was widely distributed by ME organizations through their social media networks, as well as by the Knowledge Center for Chronic Fatigue (NKCV) at Amsterdam University Medical Centers (Amsterdam UMC). “The fact that a much broader group than just the supporters of the patient organizations has been reached is evident from the fact that 45% of the participants in the survey are not members of one of these [ME] organizations,” noted the article from the ME and Disability Support Group.
NKCV is the professional home of Professor Hans Knoop, a long-time collaborator of the PACE authors and a leading light of the Dutch wing of the GET/CBT ideological brigades. I have recently criticized a study he and colleagues conducted and have claimed proves that CBT–in the form of a program called Fit after COVID–is effective in treating fatigue following an acute bout of Covid-19. (A bit more on that study below.)
Another group, Millions Missing Holland, filed an open records request with Amsterdam UMC to find out how NKCV solicited responses to the survey. Here’s what Amsterdam UMC wrote them in response:
“An attempt was made to approach as many people as possible within the patient group by providing all patients who visited Amsterdam UMC with the diagnosis of CFS/ME with a flyer containing information about the survey. In addition, this flyer was in the waiting room of Amsterdam UMC a few weeks before the target group. For approximately 150 patients it was possible to contact these patients by e-mail from the practitioner, because it was only relatively easy to retrieve their e-mail address from the file.“
In other words, patients under the care of Professor Knoop’s center, which champions the GET/CBT approach, were presumably among the survey respondents. Even so, the survey found those treatments to be “the worst” approaches to care. I look forward to seeing the full report of the survey when it’s available.
If Professor Knoop knew the results of the survey, he didn’t inform the audience in his presentation at a recent Long Covid Congress held in late November in Jena, Germany, at least judging by the available video. Instead, he presented his recent study on CBT for fatigue after an acute case of Covid-19, insisting–not surprisingly–that it showed CBT to be effective. He did not mention, nor did the trial report itself include, the very salient fact that the study’s only objective measure—how much participants moved, as measured by wearable electronic devices—yielded null results. When pressed, they offered “dog-ate-my-data” excuses for the decision to omit this key information.
Among these excuses was the claim that physical activity levels are unrelated to fatigue and that therefore the study’s null results for physical activity were unrelated to the claim that CBT was effective for self-reported fatigue. This assertion was and is ridiculous; it is hard to believe anyone would embarrass themselves by publicly making it. The assertion is also undermined by Professor Knoop’s own presentation last month, in which his slide outlining the “cognitive-behavioural model of chronic fatigue in long term medical conditions” noted that “physical inactivity” leads to fatigue. His presentation also highlighted Fit after COVID’s “graded activity” module and its role in helping patients regain their former level of activity. A graded activity module designed to increase activity would presumably be unnecessary if activity levels were unrelated to fatigue. As always, nothing Professor Knoop writes or says on these matters can be taken at face value.
***Note: My position at UC Berkeley is supported by crowdfunded donations to the university from ME/CFS patients and advocates, among others.
(Originally posted on Virology Blog.)
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@kdekooter Dat zal ongetwijfeld worden opgevoerd door #Knoop cs. Het geklungel van Vera #Bergkamp en de rest van het #presidium maakt het er niet beter op. Blijft staan dat #machtsmisbruik tegen onder jou geplaatsten altijd ernstig is en een gedegen onderzoek rechtvaardigt.
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@kdekooter Dat zal ongetwijfeld worden opgevoerd door #Knoop cs. Het geklungel van Vera #Bergkamp en de rest van het #presidium maakt het er niet beter op. Blijft staan dat #machtsmisbruik tegen onder jou geplaatsten altijd ernstig is en een gedegen onderzoek rechtvaardigt.
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@kdekooter Dat zal ongetwijfeld worden opgevoerd door #Knoop cs. Het geklungel van Vera #Bergkamp en de rest van het #presidium maakt het er niet beter op. Blijft staan dat #machtsmisbruik tegen onder jou geplaatsten altijd ernstig is en een gedegen onderzoek rechtvaardigt.
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@kdekooter Dat zal ongetwijfeld worden opgevoerd door #Knoop cs. Het geklungel van Vera #Bergkamp en de rest van het #presidium maakt het er niet beter op. Blijft staan dat #machtsmisbruik tegen onder jou geplaatsten altijd ernstig is en een gedegen onderzoek rechtvaardigt.
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By David Tuller, DrPH
I recently wrote about a Dutch study published a few months ago in the journal Clinical Infectious Diseases–“Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial.” The study, nick-named ReCOVer, found that unblinded trials relying on subjective outcomes will produce modestly positive reports in the group receiving the purportedly helpful intervention. (The senior and corresponding author was Professor Hans Knoop, a member of the CBT/GET ideological brigades.)
In this case, the intervention succeeded in prompting patients to somewhat improve their answers on questionnaires about “fatigue,” as well as about secondary domains. These results were predictable and essentially meaningless, given the bias inherent in an unblinded trial relying on self-reported measures. Nonetheless, the study has been touted by credulous observers as “evidence” that cognitive behavior therapy (CBT) is effective in preventing or reducing a core symptom associated with long Covid. Perhaps these observers are not bothered by the investigators’ decision to withhold the information that the intervention did not increase participants’ level of physical activity—the trial’s one objective outcome.
To recap: For 14 days at baseline and at the end of therapy, as outlined in the trial protocol, ReCOVer participants wore small devices measuring physical activity levels. The omission of these actigraphy results from the published paper indicated that they likely showed no difference in physical activity between the study arms and therefore did not bolster claims that the intervention was effective.
In their response to correspondence, Professor Knoop and his co-authors acknowledged as much–they had null results for actigraphy, although they provided no specifics. But they offered laughable justifications—what I earlier called “dog-ate-my-data” excuses–for having omitted these data from the paper. In the correspondence, they defended their preference for subjective indicators by arguing that “proposed alternative outcomes, like physical activity assessed with actigraphy or physical fitness are no[t] reliable markers of fatigue.”
This argument—that these outcomes are essentially irrelevant in assessing fatigue–is transparently self-serving. If people hold the absolutist position that the only valid measure for “fatigue” is a self-reported questionnaire in an unblinded trial, then of course they will reject as unreliable any null results for objective measures of physical fitness and physical activity. But it’s hard to imagine any serious investigator stooping to such ridiculousness in an effort to explain away inconvenient results. It’s an embarrassment.
In ReCOVer, after all, the CBT program is called Fit After Covid–a name that is itself an acknowledgement that seeking to improve physical fitness is an integral aspect and goal of the intervention. This acknowledgement is inconsistent with the assertion that “physical fitness” and actigraphy are not “reliable markers of fatigue.” Moreover, Fit After Covid includes a module on graded exercise, an approach grounded in the assumption of a relationship between physical activity and fatigue. The insistence on the part of Professor Knoop and his colleagues that results for physical activity have no relationship to fatigue cannot be taken seriously—except as an attempt to downplay or bury findings that raise questions about their claims regarding the effectiveness of CBT.
It is worth pointing out that Professor Knoop himself took the opposite view about the relationship between fatigue and physical activity as a co-author of a 2013 paper titled “Relationship between objectively assessed physical activity and fatigue in patients with rheumatoid arthritis: inverse correlation of activity and fatigue.”
This 2013 study offered this context: “A few other studies have investigated the association between physical activity and fatigue, and none of these studies included patients with RA [rheumatoid arthritis].” The study found that, “among patients with RA, a higher level of daily physical activity was associated with reduced levels of fatigue.” Ok, then!
And here are some other quotes from the 2013 study on RA:
*“It is important to note that decreased physical activity has been associated with increased fatigue in patients with CFS, Sjogren’s disease, and breast cancer.”
*“Fatigue is generally associated with low physical activity in patients with various chronic medical conditions.”
*“Among other patient groups [that is, non-RA patient groups], including patients with multiple sclerosis, increased physical activity (measured objectively) has been associated with decreased fatigue.”
Interestingly, the authors of the study on CBT for long Covid did not cite this 2013 publication co-authored by Professor Knoop when justifying the omission of objective outcome data on the grounds that they were irrelevant in assessing fatigue.
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A 2010 study as grounds for dismissing links between fatigue and physical activity
How is it possible to justify the premise that markers of physical activity are unreliable or irrelevant when it comes to fatigue? Well, Professor Knoop and colleagues enshrined this notion as an actual thing—an academic finding!—in a 2010 paper.
In the 2000s, three separate Dutch trials of CBT for what was then being called chronic fatigue syndrome (CFS) reported positive results for subjective outcomes but null results for actigraphy. In all three cases, the initial trial reports omitted mention of the objective results and presented CBT as effective based on the other measures. This selective reporting led to an incomplete–and false–public understanding of the outcomes. When Professor Knoop and colleagues finally revealed the poor actigraphy findings from all three papers in 2010, they dismissed them as having no relationship to fatigue.
The 2010 paper was called “How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity.” Accepting the positive subjective fatigue findings at face value, the investigators analyzed the lack of comparable benefits on actigraphy. The study concluded that physical activity is essentially irrelevant when measuring fatigue: “Although CBT effectively reduced fatigue, it did not change the level of physical activity…The effect of CBT on fatigue in CFS is not mediated by a persistent increase in physical activity.”
Scientists beyond the grip of this particular form of groupthink might have interpreted the results differently. They would likely have suggested that the null results for actigraphy across all three CBT trials raised questions about whether the self-reported reductions in fatigue were partly or largely artifacts of the bias built into the design of the studies. But these Dutch investigators took the opposite view.
Here’s a key section of their 2010 paper: “Our study was the first one to show that the severity of fatigue in patients with CFS is not reduced by CBT because patients have become more physically active at the end of their treatment. Based on these findings, physical activity programmes can better be understood as a way to facilitate change in other mechanisms which are more directly related to a change in fatigue. Among these mechanisms, a change in illness-related cognitions is likely to play a crucial role in CBT for CFS and should therefore be monitored closely during treatment.”
Per this interpretation, in other words, the level of physical activity doesn’t matter when it comes to fatigue, so physical activity programs should focus less on actual physical activity and more on inducing “a change in illness-related cognitions” and “other mechanisms…more directly related to fatigue.” These recommendations would seem to undermine the rationale for long-standing treatments like graded exercise therapy and physical activity programs. But such contradictions do not seem to trouble Professor Knoop and his team.
It remains perplexing that well-regarded investigators would advance such an untenable argument, whether in 2010 or this year, to justify withholding key objective information from the public record. But that’s where we are. As I wrote last month on Twitter (now X) after having seen a production of The Crucible, the arguments for witchcraft in the play were more persuasive than the gibberish offered by authors of the recent CBT-for-long-Covid study to justify their flawed decision-making.
(Originally posted on Virology Blog.)
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By David Tuller, DrPH
Slate recently ran a piece by a young journalist and Stanford neuroscience graduate student, Grace Huckins, about purported links between long Covid and mental illness. I found it problematic. For one thing, in the same sentence it linked to both a story of mine in Codastory.com and one from The Atlantic‘s Ed Yong, and asserted that both of our articles “suggested that linking depression and long COVID is tantamount to accusing all long COVID sufferers of being malingerers.”
This was not remotely the point I was trying to make; I can’t speak for Ed, but I didn’t read his article that way either. My piece was about physicians smacked by long Covid who have been told categorically that depression, anxiety and what-not are the cause of all their devastating symptoms and that absolutely no pathophysiological processes are implicated. I highlighted this point and a couple of others on Twitter and suggested that the journalist and I meet up to discuss the issues, since we’re both in the San Francisco area. (I would have DM’d her if that had been possible on Twitter.)
In response, she offered to DM me. She also indicated that she had been “deeply troubled by some of your writing (I have read quite a lot of it), which in my eyes goes against the scientific evidence.” As of now, I haven’t heard from her, so I remain curious about what I have written that she views as antithetical to the science.
Perhaps this concern involves my clearly negative view of a Dutch study of cognitive behavior therapy for long Covid. My piece included some harsh words about this study, which was still ongoing at the time. The study results were published earlier this year. The Slate piece highlighted the positive reported findings as legitimate evidence for the effectiveness of this sort of intervention. I think the study stinks–not least because the authors have acknowledged after-the-fact that they had null results for their sole objective outcome–activity as measured by actometer worn for a week or two.
In retrospect, I should have made clearer that much of my objection to the study related to its provenance. Professor Hans Knoop, the senior author, is an unreliable narrator when it comes to his own study findings. There are good reasons not to take his work at face value. Just one example is how he and a senior colleague wrote in a 2011 Lancet commentary that PACE participants met a “strict criterion for recovery”—an absurd statement. It was self-evident that the trial was designed in a way that would almost guarantee positive results.
But I certainly did not suggest there was no link between depression and long Covid. You’d have to be dense, clueless or stupid to make that argument. (I am, of course, very capable of being all three of those. Just ask my ex-boyfriends!)
Anyway, after that, I posted a long thread about some other aspects of the Slate article. Someone kindly unspooled it for me, so I’m posting it here.
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The recent article in @Slate by @grace_huckins attracted a lot of attention. The article highlighted the self-evident links between mood/psychological states and somatic symptoms. No argument there–no one seriously disputes the links. 1/
But the article relies heavily on the construct of functional neurological disorder without noting how FND experts have misrepresented their own field for more than a decade, as I have recently reported.2/
The top experts in the field have routinely disseminated false information about prevalence from a seminal study in their field, insisting that it showed that 16% of neurology outpatients had FND and that it was the #2 diagnosis. This claim is nonsense.3/
The 2010 study, Stone et al, found that 5.5% had conversion disorder, now known as FND–not 16%. At that lower rate, it was the 8th-most-common diagnosis, not #2. This is indisputable, as evidenced by the forthcoming correction in a major journal. 4/
This correction will necessitate further corrections in literally dozens of papers. The #2 diagnosis claim has become a meme–even though the paper cited showed no such thing. The others included had “functional” disorders but no evidence of the specific Dx of FND.5/
As the Slate article notes, an FND Dx requires the presence of positive findings on clinical “rule-in” signs–it is purportedly a positive diagnosis, while so-called “functional” disorders are considered diagnoses of exclusion. 6/
The Slate article notes that “there are specific clues that doctors can use to identify FND.” A major problem is that the studies about these clues–the “rule-in” signs–do not tell us very much, as I recently documented about Hoover’s sign 7/
Hoover’s sign is the “poster-sign” for FND, first described a century ago as a way to identify hysterical leg weakness/paralysis from the “organic” version. It is routinely claimed that it is 100% specific, or close to. But the main study finding tells us very little about FND.8/
In this decade-old study, the authors found Hoover’s sign in less than 20 patients previously diagnosed with FND (or conversion disorder) and didn’t find it in the comparison group. So why doesn’t this mean it is 100% specific in identifying FND? 9/
Because all the FND patients had a positive Hoover’s sign as part of their diagnostic work-up in the first place–in other words, it was part of why they were given the Dx. So it is not surprising that they would have a second positive Hoover’s sign. /10
In other words, the study proved that one positive Hoover’s sign predicts another–nothing more. The authors noted the circularity of the argument as a limitation. But it is more than a minor limitation–it renders meaningless the purported specificity of Hoover’s for FND. 11/
The authors themselves called for more studies of Hoover’s sign, including of inter-rater reliability studies. But neither they nor others have conducted these further studies. So we are left with proof that a positive Hoover’s sign predicts another positive Hoover’s sign. 12/
It is known that other conditions with known pathophysiological processes can lead to positive Hoover’s signs. And yet based on this meager set of data, it is also said to be close to 100% specific for FND. And Hoover’s is the most studied of the signs. 13/
It is hard to take at face value the claims of experts who have spent a decade misrepresenting key data from their field of expertise and over-hyping the “high specificity” of clinical signs studied in papers with circular study designs.14/
A 2021 paper on these signs included this statement: ““There is a need to further test the specificity, sensitivities and inter-rater reliability of the growing range of positive functional signs compared to other neurological populations…15/
…particularly given that statistical properties for some signs have been only tested in a single cohort.” In fact, almost all of the signs identified to test motor FND have been tested in only a single cohort. (My above-linked blog post contains all links and references). 16/
A 2022 paper included a table of 41 “validated positive motor signs” used to rule in the motor FND diagnoses 34 of these–or 83%–were shown as tested in only a single cohort. Five were tested in two studies, and only two signs were tested in more than two.17/
It is self-evident that mood states/depression/anxiety impact the body in incredibly complicated ways. No one seriously disputes that these can cause and exacerbate a range of conditions. No one can seriously dispute that psychotherapy can be helpful in a great many ways. 18/
But the CBT promoters in the long Covid field, like the senior author of the study cited favorably in Slate, are not honest brokers, just like the CBT promoters for ME/CFS are not honest brokers. A close looks at the Dutch study for CBT for long covid makes that clear. 19/
That study–like almost every CBT study in this domain of illnesses with non-specific symptoms like ME/CFS–relied for its claims of success solely on subjective outcomes. In an unblinded study, relying on subjective outcomes is a recipe for an enormous amout of bias. 20/
It is self-evident, or should be, that patients who receive loving attention from a therapist for months are more likely to respond more positively on questionnaires than patients who received nothing. Hello!! Can anybody seriously argue the opposite? 21/
Anyone who receives a course of CBT from a compassionate person is likely to report some benefit, whether they have an illness or not. To argue from this that modest reported benefits demonstrate the efficacy of the treatment requires a problematic suspension of skepticism.22/
Beyond that, the senior author has a history of hiding null or poor results on a key objective measure of movement–actigraphy readings from a device worn for days or a week by participants. I reported on this in a recent blog.23/
Three major Dutch studies of psycho-behavioral interventions for ME/CFS all had positive subjective findings but null objective actigraphy findings. And all the papers were published without the objective findings and touted as proof the treatments worked.24/
Only years later did these authors, including Knoop, publish their null objective results. But of course by then no one cared or paid attention. In the recent LC study of CBT, the protocol indicated that actigraphy would be done at baseline and three months. 25/
So where are these data? The published report doesn’t mention them. I think it’s fair to assume that if they supported the subjective results, the authors would have included them. Their absence suggests that, like in past CBT studies, they contradict the subjective outcomes. 26/
There are other issues with this study, as noted in a recently published response to it. Citing this as serious evidence that CBT works for long covid is really unwarranted.
The Slate article criticized an article I wrote about clinicians with long Covid. In that article, I mentioned that this Dutch CBT study was underway and criticized it. The point is not that I reject all research into the links between long covid and depression/anxiety/etc. 28/
The linkages are obviously there, depression and anxiety and constant stress response are obviously harmful to physiological processes. But I strenuously object to researchers who have a history of problematic reporting of their results. 29/
That includes investigators who have spent a decade misrepresenting a seminal study in their field of research, who over-hype the specificity and discriminatory value of clinical signs, and who hide salient objective results from their own studies. 30/
This means I also tend to have objections to journalism articles that rely on these claims. The Slate article seems to me much more nuanced in the end from related articles in New York and The New Republic. The journalist appears more open to dialogue. 31/
I continue to be open to having that dialogue with her, and with other journalists engaged in these issues. Certainly I hope in future those tackling this issue take a sharper look at some of the studies they are citing and the robust critiques of those studies. 32/
That’s all for now on this. I might have more thoughts on it later.
Oh, one more point–the Slate author makes it clear that association is not causation, that investigations into biomedical causes are critical, etc. In many ways, it is a nuanced piece. But the piece overlooks that the approach of the CBT experts in this domain is different.
In general, their argument has been that these anxiety/depression are the sole causes of all the non-specific symptoms. Patients are not told generally they have associated depresion/anxiety but that those are THE causal factors. That’s the issue.
(Originally posted on Virology Blog.)
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By David Tuller, DrPH
Three years ago, I wrote a blog post about a problematic Dutch study that had been funded by a major health agency and was being led by Hans Knoop, a professor of medical psychology at Amsterdam University Medical Centers. The study sought to test whether a course of cognitive behavior therapy starting months after a bout of acute Covid-19—rather than years later— could reduce levels of reported fatigue and prevent it from becoming chronic.
Professor Knoop is a long-time colleague of the authors of the now-discredited PACE trial. In a Lancet commentary accompanying the publication of the PACE results, he and a colleague declared that many patients had met “a strict criterion for recovery”—a ridiculous and untrue claim.
This new study—like so much of the research from Professor Knoop and his colleagues in the world of psychosomatic medicine—was unblinded and relied on subjective, self-reported outcomes. This design is fraught with potential bias. Given the design, the study was destined to produce positive results on these subjective outcomes—and now, not surprisingly, it has, with the results published in the journal Clinical Infectious Diseases.
Also not surprisingly, the results for the one objective outcome included in the protocol—actigraphy to measure levels of physical activity at baseline and right after treatment—were not reported or mentioned in the paper. Professor Knoop has deployed this strategy before—most recently in 2017 when he and colleagues published positive subjective outcomes but failed to report null actometer results in a study of CBT for treating fatigue after Q-fever; these null results were published two years later and ignored. And in a similar fashion a dozen years ago, Professor Knoop and several colleagues buried disappointing actigraphy results from three trials of CBT for ME/CFS.
Twitter threads from @lucibee and @anilvanderzee point out some of the major issues with the new study, called “Efficacy of cognitive behavioral therapy targeting severe fatigue following COVID-19: the results of a randomized controlled trial.” The study was also the subject of a lively discussion on the Science For ME forum. The CBT course, called “Fit After Covid,” included online modules along with in-person or online contact with a therapist.
The study’s 114 participants were all suffering from what was identified as severe fatigue three to 12 months after their acute infections. They were randomized into a group receiving the CBT program and group receiving care as usual (CAU)—a design that undermines the claim in the article title that the study was “controlled.”
Yes, there was a comparison arm. But the mean number of interactions between therapist and patient in the CBT arm was almost 12, and the study did not offer members in the CAU group a parallel amount of time and attention.
If participants know they are receiving an active treatment in a trial—a full course of therapeutic encouragement, for example—and they are told that this treatment has been found to be successful in other circumstances, it stands to reason they would be more likely to report benefits than people who know they did not receive the possibly helpful treatment. The authors mention this imbalance between the groups as a limitation but nonetheless still call the trial “controlled,” even though they are not controlling for this important factor.
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CBT targets seven domains of thought and activity
The trial was based on a “cognitive-behavioral model” and the CBT was specifically designed to target seven perceived domains that could perpetuate the fatigue. These were: a disrupted sleep-wake pattern, unhelpful beliefs about fatigue, a low or unevenly distributed activity level, perceived low social support, problems with psychological processing of COVID-19, fears and worries regarding COVID-19, and poor coping with pain. The CBT group received the intervention for 17 weeks.
Let’s be clear. Everyone who has been sick could benefit from someone—a good social worker, a life coach, grandma, a counselor, or a CBT therapist—offering them common sense advice about sleep and activity levels and the need to find more friends or call their siblings if they’re feeling low. Of course it is useful to help people address fears and worries about the pandemic. All these things are likely to make them feel better, emotionally and physically, especially compared to people who are not offered anything comparable.
And of course that will make them more likely to answer more positively in general on questionnaires, including fatigue questionnaires. That doesn’t mean you’re treating anyone’s fatigue—just that you’re providing human and social support of the kind we all could benefit from in tough times. It should be expected that this would be reflected in modest improvements in questionnaire scores—especially in an open label trial in which people know they are getting a “treatment” that they believe could help them get better.
The authors acknowledged this limitation but noted that members of the CAU group were able to access other treatments that could have helped provide some balance to the experiences of the separate arms. The paper noted, for example, that “most participants in the CAU group members of the CAU group received care, including exercise.”
Uh, oh! The study makes no mention of post-exertional malaise (PEM), a core characteristic of ME/CFS and in many cases of long Covid. If some CAU group members had PEM and were being encouraged to exercise, that could explain why they reported worse fatigue at the end. It might also explain why the CBT group had fewer reported adverse events than the CAU group.
Besides fatigue, the participants were required as an entry requirement to demonstrate limitations in physical function by a low score on a questionnaire and/or limitations in “social functioning” on a different scale. This raises the possibility that some were suffering from primary depression rather than being physically disabled. Any such patients might well have benefited from a course of CBT, which is frequently prescribed treatment for depression.
The trial’s primary outcome was the difference in the means between the two groups right after treatment and six months later on the fatigue severity sub-scale of the Checklist Individual Strength (CIS), a 20-item fatigue questionnaire. The fatigue severity sub-scale has eight items, with each one rated on a 1-7 scale, with higher scores indicating greater fatigue. The total score ranges from a low of eight to a hight of 52.
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No objective findings but modest subjective results
The study showed—wow!—that those who received the intervention said they were less tired than those that didn’t get the intervention. The overall mean for the CBT group’s CIS scores right after treatment and six months later was 8.8 points lower than the the mean for the CAU group. This is not a huge gap on a 52-point scale. The mean score for the CBT group at six months—31.5—still represents significant fatigue. The difference between the groups seems well within what one might expect from any bias stemming from the study design.
Secondary measures—all subjective—also favored the intervention.
But the absence of the actigraphy results casts doubt on even these modest reported subjective benefits. The actigraphy results would have revealed participants’ objective levels of physical activity. The protocol called for participants to wear actigraphs around their wrists to monitor their activity for 14 days, both at the start of the trial and right at the end of the course of therapy. (For unexplained reasons, the protocol did not call for actigraphy at the six-month post-therapy time point.)
Beyond not providing the results, the authors didn’t explain why they decided not to provide them. This omission of salient data aligns with past practice by Dutch investigators in this domain—including Professor Knoop. Besides the 2017 Q-fever study, in three previous Dutch studies for psycho-behavioral interventions for ME/CFS that included actigraphy as an outcome, the authors published the positive subjective outcomes in the initial papers but left out the objective outcome.
Finally, years later, they published the actigraphy results from all three papers in a single article. The actigraphy had null results in all three studies. “Although CBT effectively reduced fatigue, it did not change the level of physical activity,” concluded the authors, including Professor Knoop. In other words, the CBT appeared to improve reporting on fatigue questionnaires but did not lead to any real change in how much people do physically. This apparent conflict between subjective and objective outcomes did not shake the authors’ confidence in the accuracy of the former.
In this case, it is hard to imagine that Professor Knoop would have omitted the actigraphy results from the published report had they documented that CBT conferred objective measurable benefits. What reason would there be? But if they showed no change in the CBT group, or worse, and Professor Knoop publishes those data two years from now, no one will notice. The study has already been published with modestly positive subjective findings, and that’s already sucked up the attention.
(Originally posted on Virology Blog.)
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By David Tuller, DrPH
Three years ago, I wrote a blog post about a problematic Dutch study that had been funded by a major health agency and was being led by Hans Knoop, a professor of medical psychology at Amsterdam University Medical Centers. The study sought to test whether a course of cognitive behavior therapy starting months after a bout of acute Covid-19—rather than years later— could reduce levels of reported fatigue and prevent it from becoming chronic.
Professor Knoop is a long-time colleague of the authors of the now-discredited PACE trial. In a Lancet commentary accompanying the publication of the PACE results, he and a colleague declared that many patients had met “a strict criterion for recovery”—a ridiculous and untrue claim.
This new study—like so much of the research from Professor Knoop and his colleagues in the world of psychosomatic medicine—was unblinded and relied on subjective, self-reported outcomes. This design is fraught with potential bias. Given the design, the study was destined to produce positive results on these subjective outcomes—and now, not surprisingly, it has, with the results published in the journal Clinical Infectious Diseases.
Also not surprisingly, the results for the one objective outcome included in the protocol—actigraphy to measure levels of physical activity at baseline and right after treatment—were not reported or mentioned in the paper. Professor Knoop has deployed this strategy before—most recently in 2017 when he and colleagues published positive subjective outcomes but failed to report null actometer results in a study of CBT for treating fatigue after Q-fever; these null results were published two years later and ignored. And in a similar fashion a dozen years ago, Professor Knoop and several colleagues buried disappointing actigraphy results from three trials of CBT for ME/CFS.
Twitter threads from @lucibee and @anilvanderzee point out some of the major issues with the new study, called “Efficacy of cognitive behavioral therapy targeting severe fatigue following COVID-19: the results of a randomized controlled trial.” The study was also the subject of a lively discussion on the Science For ME forum. The CBT course, called “Fit After Covid,” included online modules along with in-person or online contact with a therapist.
The study’s 114 participants were all suffering from what was identified as severe fatigue three to 12 months after their acute infections. They were randomized into a group receiving the CBT program and group receiving care as usual (CAU)—a design that undermines the claim in the article title that the study was “controlled.”
Yes, there was a comparison arm. But the mean number of interactions between therapist and patient in the CBT arm was almost 12, and the study did not offer members in the CAU group a parallel amount of time and attention.
If participants know they are receiving an active treatment in a trial—a full course of therapeutic encouragement, for example—and they are told that this treatment has been found to be successful in other circumstances, it stands to reason they would be more likely to report benefits than people who know they did not receive the possibly helpful treatment. The authors mention this imbalance between the groups as a limitation but nonetheless still call the trial “controlled,” even though they are not controlling for this important factor.
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CBT targets seven domains of thought and activity
The trial was based on a “cognitive-behavioral model” and the CBT was specifically designed to target seven perceived domains that could perpetuate the fatigue. These were: a disrupted sleep-wake pattern, unhelpful beliefs about fatigue, a low or unevenly distributed activity level, perceived low social support, problems with psychological processing of COVID-19, fears and worries regarding COVID-19, and poor coping with pain. The CBT group received the intervention for 17 weeks.
Let’s be clear. Everyone who has been sick could benefit from someone—a good social worker, a life coach, grandma, a counselor, or a CBT therapist—offering them common sense advice about sleep and activity levels and the need to find more friends or call their siblings if they’re feeling low. Of course it is useful to help people address fears and worries about the pandemic. All these things are likely to make them feel better, emotionally and physically, especially compared to people who are not offered anything comparable.
And of course that will make them more likely to answer more positively in general on questionnaires, including fatigue questionnaires. That doesn’t mean you’re treating anyone’s fatigue—just that you’re providing human and social support of the kind we all could benefit from in tough times. It should be expected that this would be reflected in modest improvements in questionnaire scores—especially in an open label trial in which people know they are getting a “treatment” that they believe could help them get better.
The authors acknowledged this limitation but noted that members of the CAU group were able to access other treatments that could have helped provide some balance to the experiences of the separate arms. The paper noted, for example, that “most participants in the CAU group members of the CAU group received care, including exercise.”
Uh, oh! The study makes no mention of post-exertional malaise (PEM), a core characteristic of ME/CFS and in many cases of long Covid. If some CAU group members had PEM and were being encouraged to exercise, that could explain why they reported worse fatigue at the end. It might also explain why the CBT group had fewer reported adverse events than the CAU group.
Besides fatigue, the participants were required to demonstrate limitations in physical function by a low score on a questionnaire and/or limitations in “social functioning” on a different scale. This raises the possibility that some were suffering from primary depression rather than being physically disabled. Any such patients might well have benefited from a course of CBT, which is frequently prescribed treatment for depression.
The trial’s primary outcome was the difference in the means between the two groups right after treatment and six months later on the fatigue severity sub-scale of the Checklist Individual Strength (CIS), a 20-item fatigue questionnaire. The fatigue severity sub-scale has eight items, with each one rated on a 1-7 scale, with higher scores indicating greater fatigue. The total score ranges from a low of eight to a hight of 52.
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No objective findings but modest subjective results
The study showed—wow!—that those who received the intervention said they were less tired than those that didn’t get the intervention. The overall mean for the CBT group’s CIS scores right after treatment and six months later was 8.8 points lower than the the mean for the CAU group. This is not a huge gap on a 52-point scale. The mean score for the CBT group at six months—31.5—still represents significant fatigue. The difference between the groups seems well within what one might expect from any bias stemming from the study design.
Secondary measures—all subjective—also favored the intervention.
But the absence of the actigraphy results casts doubt on even these modest reported subjective benefits. The actigraphy results would have revealed participants’ objective levels of physical activity. The protocol called for participants to wear actigraphs around their wrists to monitor their activity for 14 days, both at the start of the trial and right at the end of the course of therapy. (For unexplained reasons, the protocol did not call for actigraphy at the six-month post-therapy time point.)
Beyond not providing the results, the authors didn’t explain why they decided not to provide them. This omission of salient data aligns with past practice by Dutch investigators in this domain—including Professor Knoop. Besides the 2017 Q-fever study, in three previous Dutch studies for psycho-behavioral interventions for ME/CFS that included actigraphy as an outcome, the authors published the positive subjective outcomes in the initial papers but left out the objective outcome.
Finally, years later, they published the actigraphy results from all three papers in a single article. The actigraphy had null results in all three studies. “Although CBT effectively reduced fatigue, it did not change the level of physical activity,” concluded the authors, including Professor Knoop. In other words, the CBT appeared to improve reporting on fatigue questionnaires but did not lead to any real change in how much people do physically. This apparent conflict between subjective and objective outcomes did not shake the authors’ confidence in the accuracy of the former.
In this case, it is hard to imagine that Professor Knoop would have omitted the actigraphy results from the published report had they documented that CBT conferred objective measurable benefits. What reason would there be? But if they showed no change in the CBT group, or worse, and Professor Knoop publishes those data two years from now, no one will notice. The study has already been published with modestly positive subjective findings, and that’s already sucked up the attention.
(Originally posted on Virology Blog.)
