The limited evidence base means that NG188 lacks detail about potentially beneficial rehabilitative interventions such as breathing exercises or cognitive behavioural therapy (CBT). Nor does it caution against specific interventions.7

A particular concern is around the potential dangers of the effects of exercise in some patients, such as those with undiagnosed acute pericarditis or myocarditis.

NICE’s clinical guideline for chronic fatigue syndrome(CFS)/myalgic encephalomyelitis (ME) from 2007 (CG53) recommends CBT and/or graded exercise therapy for people with mild to moderate CFS/ME. In July 2020, however, NICE acknowledged concerns about graded exercise therapy for people recovering from COVID-19, saying that “it should not be assumed that the [CG53] recommendations apply to people with fatigue following COVID-19.” NG188 lacks this clarification.8,9

Responding to NG188, a medical advisor to the ME Association, Dr Charles Shepherd, warned that inappropriate exercise testing or treatment is very likely to cause a significant degree of symptom exacerbation in a post-viral syndrome such as long COVID.7

He was also surprised that NG188 does not recognise the important clinical and pathological overlaps between long COVID and ME/CFS. Nor has NICE made use of the detailed guidance on energy and activity management in the new NICE guideline on ME/CFS with an expected publication date in April 2021.7,10