Diagnosis and Management of ME/CFS in October 2021. It was removed due to low quality evidence regarding benefit, with the guidelines now stating that clinicians should not prescribe "any programme that ... uses fixed incremental increases in physical activity or exercise, for example, graded exercise therapy." Previously, the National Institutes of Health concluded that while GET could produce benefits, it may not yield improvement in quality of life, and because of this limitation GET should not be considered as a primary treatment. It was recommended to be used only as one component of a broader approach. It noted that a focus on exercise programs had discouraged patient participation in other types of physical activity due to concerns of increased symptoms. An addendum stated, if studies based on the Oxford criteria were excluded, there would be insufficient evidence of the effectiveness of GET. A 2019 updated Cochrane review stated that, exercise therapy probably has a positive effect on fatigue in adults, and slightly improves sleep, but the long-term effects are unknown and has limited relevance to current definitions of ME/CFS. Cochrane started re-evaluating the effects of exercise therapies in chronic fatigue syndrome in 2020. Patient organisations have long criticised the use of exercise therapy, most notably GET, as a treatment for CFS. Based on an opinion survey of patients who had received GET, in 2015 the ME Association concluded, GET in its current delivered form should not be recommended as a primary intervention for persons with CFS. Adaptive pacing therapy APT, not to be confused with pacing, is a therapy rather than a management strategy. APT is based on the idea that CFS involves a person only having a limited amount of available energy, and using this energy wisely will mean the "limited energy will increase gradually". A large clinical trial known as the PACE trial found APT was no more effective than usual care or specialized medical care. The PACE trial generated much criticism due to the broad Oxford criteria patient selection, the standards of outcome effectiveness were lowered during the study and that re-analysis of the data did not support the magnitude of improvements initially reported. Unlike pacing, APT is based on the cognitive behavioral model of chronic fatigue syndrome and involves increasing activity levels, which it states may temporarily increase symptoms. In APT, the patient first establishes a baseline level of activity, which can be carried out consistently