Graded Exercise Therapy Guided Self-Help Trial for Patients with Chronic Fatigue Syndrome (GETSET): Protocol for a Randomized Controlled Trial and Interview Study

Background: Chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME), is characterized by chronic disabling fatigue and other symptoms, which are not explained by an alternative diagnosis. Previous trials have suggested that graded exercise therapy (GET) is an effective and safe treatment. GET itself is therapist-intensive with limited availability. Objective: While guided self-help based on cognitive behavior therapy appears helpful to patients, Guided graded Exercise Self-help (GES) is yet to be tested. Methods: This pragmatic randomized controlled trial is set within 2 specialist CFS/ME services in the South of England. Adults attending secondary care clinics with National Institute for Health and Clinical Excellence (NICE)-defined CFS/ME (N=218) will be randomly allocated to specialist medical care (SMC) or SMC plus GES while on a waiting list for therapist-delivered rehabilitation. GES will consist of a structured booklet describing a 6-step graded exercise program, supported by up to 4 face-to-face/telephone/Skype™ consultations with a GES-trained physiotherapist (no more than 90 minutes in total) over 8 weeks. The primary outcomes at 12-weeks after randomization will be physical function (SF-36 physical functioning subscale) and fatigue (Chalder Fatigue Questionnaire). Secondary outcomes will include healthcare costs, adverse outcomes, and self-rated global impression change scores. We will follow up all participants until 1 year after randomization. We will also undertake qualitative interviews of a sample of participants who received GES, looking at perceptions and experiences of those who improved and worsened. Results: The project was funded in 2011 and enrolment was completed in December 2014, with follow-up completed in March 2016. Data analysis is currently underway and the first results are expected to be submitted soon. Conclusions: This study will indicate whether adding GES to SMC will benefit patients who often spend many months waiting for rehabilitative therapy with little or no improvement being made during that time. The study will indicate whether this type of guided self-management is cost-effective and safe. If this trial shows GES to be acceptable, safe, and comparatively effective, the GES booklet could be made available on the Internet as a practitioner and therapist resource for clinics to recommend, with the caveat that patients also be supported with guidance from a trained physiotherapist. The pragmatic approach in this trial means that GES findings will be generalizable to usual National Health Service (NHS) practice.

Embracing difference and the deferral of self-government: a critical analysis of the framing and practice of contemporary peace building

This thesis analyses how dominant policy approaches to peacebuilding have moved away from a single and universalised understanding of peace to be achieved through a top-down strategy of democratisation and economic liberalisation, prevalent at the beginning of 1990s. Instead, throughout the 2000s, peacebuilders have increasingly adopted a commitment to cultivating a bottom-up and hybrid peace building process that is context-sensitive and intended to be more respectful of the needs and values of post-war societies. The projects of statebuilding in Kosovo and, to a lesser extent, in Bosnia are examined to illustrate the shift. By capturing this shift, I seek to argue that contemporary practitioners of peace are sharing the sensibility of the theoretical critics of liberalism. These critics have long contended that post-war societies cannot be governed from ‘above’ and have advocated the adoption of a bottom-up approach to peacebuilding. Now, both peace practitioners and their critics share the tendency to embrace difference in peacebuilding operations, but this shift has failed to address meaningfully the problems and concerns of post-conflict societies. The conclusion of this research is that, drawing on the assumption that these societies are not capable of undertaking sovereign acts because of their problematic inter-subjective frames, the discourses of peacebuilding (in policy-making and academic critique) have increasingly legitimised an open-ended role of interference by external agencies, which now operate from ‘below’. Peacebuilding has turned into a long-term process, in which international and local actors engage relationally in the search for ever-more emancipatory hybrid outcomes, but in which self-government and self-determination are constantly deferred. Processes of emphasising difference have thus denied the political autonomy of post-war societies and have continuously questioned the political and human equality of these populations in a hierarchically divided world.

Can the European Union build a bridge over troubled waters? An analysis of the politicised and depoliticised legal approach between the European Union and Cyprus

The Cyprus dispute accurately portrays the evolution of the conflict from ‘warfare to lawfare’ enriched in politics; this research has proven that the Cyprus problem has been and will continue to be one of the most judicialised disputes across the globe. Notwithstanding the ‘normalisation’ of affairs between the two ethno-religious groups on the island since the division in 1974, the Republic of Cyprus’ (RoC) European Union (EU) membership in 2004 failed to catalyse reunification and terminate the legal, political and economic isolation of the Turkish Cypriot community. So the question is; why is it that the powerful legal order of the EU continuously fails to tame the tiny troublesome island of Cyprus? This is a thesis on the interrelationship of the EU legal order and the Cyprus problem. A literal and depoliticised interpretation of EU law has been maintained throughout the EU’s dealings with Cyprus, hence, pre-accession and post-accession. The research has brought to light that this literal interpretation of EU law vis-à-vis Cyprus has in actual fact deepened the division on the island. Pessimists outnumber optimists so far as resolving this problem is concerned, and rightly so if you look back over the last forty years of failed attempts to do just that, a diplomatic combat zone scattered with the bones of numerous mediators. This thesis will discuss how the decisions of the EU institutions, its Member States and specifically of the European Court of Justice, despite conforming to the EU legal order, have managed to disregard the principle of equality on the divided island and thus prevent the promised upgrade of the status of the Turkish Cypriot community since 2004. Indeed, whether a positive or negative reading of the Union’s position towards the Cyprus problem is adopted, the case remains valid for an organisation based on the rule of law to maintain legitimacy, democracy, clarity and equality to the decisions of its institutions. Overall, the aim of this research is to establish a link between the lack of success of the Union to build a bridge over troubled waters and the right of self-determination of the Turkish Cypriot community. The only way left for the EU to help resolve the Cyprus problem is to aim to broker a deal between the two Cypriot communities which will permit the recognition of the Turkish Republic of Northern Cyprus (TRNC) or at least the ‘Taiwanisation’ of Northern Cyprus. Albeit, there are many studies that address the impact of the EU on the conflict or the RoC, which represents the government that has monopolised EU accession, the argument advanced in this thesis is that despite the alleged Europeanisation of the Turkish Cypriot community, they are habitually disregarded because of the EU’s current legal framework and the Union’s lack of conflict transformation strategy vis-à-vis the island. Since the self-declared TRNC is not recognised and EU law is suspended in northern Cyprus in accordance with Protocol No 10 on Cyprus of the Act of Accession 2003, the Turkish-Cypriots represent an idiomatic partner of Brussels but the relations between the two resemble the experience of EU enlargement: the EU’s relevance to the community has been based on the prospects for EU accession (via reunification) and assistance towards preparation for potential EU integration through financial and technical aid. Undeniably, the pre-accession and postaccession strategy of Brussels in Cyprus has worsened the Cyprus problem and hindered the peace process. The time has come for the international community to formally acknowledge the existence of the TRNC.