Graded exercise therapy

Graded exercise therapy (GET) is a form of physical therapy for the management of chronic fatigue syndrome where physical activity is gradually increased over time. It is a treatment offered to ME/CFS patients in the UK in the National Health Service as specified in the NICE guidelines. The PACE trial was designed to confirm that the NICE Guidelines were effective. The fact that the objective measures of success as found by the PACE trial authors were null at the one year follow up, hasn't stopped the PACE trial authors from claiming the effectiveness of GET and CBT. The trial found that people severely ill at the beginning of a trial,( despite being 25% improved and called moderately recovered by the end of the trial) were objectively only slightly less severely ill, as measured by the 6 minute walking test. Another way of interpreting the 6 minute walking test is that patients with an average age of 40, are moderately recovered when they can walk at the same rate as healthy 80 year olds.

The PACE trial demonstrated that the form of GET described in the UK- NICE Guidelines is ineffective, at best. Further, in the NICE-model, the exercise is "prescribed" for people with ME/CFS without taking into account the physiological abnormalities, caused by the disease, and the patients dysfunctional reactions to exercise [page 4 CCC-need to find original sources due to copyright restrictions-  ] [page 3 ICC. The decision to avoid exercise by many patients with ME/CFS has been described as a logical and learned response to a "noxious stimulant"  (Mark VanNesss).

Many people with ME/CFS do not have the capacity to add extra exercise in to their day to day lives, without exacerbating their symptoms, and causing their health to deteriorate. Their extraordinary low level of physical capacity, and abnormal response to exertion, means that for many patients, the exertion of daily living is already pushing them into a push/crash mode of living i.e. pushing and getting things done on a good day, only to crash for the next 3-4 days  (Alison Bested- video). Given the documented abnormal response to exercise, it is not surprising that when the UK MEAssociation, surveyed its members it found that 74% of them had been harmed by GET. In a similar survey, Emerge Australia found that 90% of participants had been harmed by GET (unpublished).

In the context of these patient surveys, graded exercise therapy was taken to mean the narrow definition that it has been given in the UK NICE guidelines and the UK PACE manual. In the UK documents the term graded exercise therapy (GET), is defined as an exercise program based on the premise, that disease fits a biopsychosocial model of causation, symptoms are caused by patients developing a "false illness belief" and an unwarranted resistance to exercise i.e. it is a somatoform disorder and a "medically unexplained syndrome". Some of the proponents of these "narrow" types of GET programs advise patients, to ignore symptoms entirely, whilst others suggest that patients don't exacerbate their symptoms. The practitioners with UK-NICE view of ME/CFS, typically, do not screen the patients for orthostatic intolerance or quantify their abnormal responses to exercise, and the programs are not normally guided by the patients symptoms or physiological response to exercise e.g. heart rate, heart rate variability and temperature changes.

In Australia and the USA]} some medical professionals use the term graded exercise therapy more broadly than the [[NICE/PACE trial definition used in the UK. Many use the term graded exercise therapy (GET), to mean any exercise program, in which the amount of exercise being undertaken is increased over time and base their programs on the patients physiological response to exercise and symptomology.

In the USA some practitioners have used a variety of names to distinguish their programs from the UK-NICE-GET e,g. "safe exercise" (Klimas- i think), energy conservation and aneleptic exercise (Mark VanNess), pacing with a heart rate monitor (Bruce Campbell), restorative exercise (Staci Stevens

In Australia sessions of GET, with an allied health care professional are subsidised on a chronic health care plan, what is meant by GET depends on the individual practitioner, their knowledge of/or receptiveness to learn about ME/CFS. Mark VanNess (video?) suggests asking an exercise phsyiologsit not familiar with ME/CFS for a program suitable for an 80 year old with severe heat disease. Some Australian "fatigue clinics" have programs similar to the UK-NICE model UK

People with ME/CFS face an exercise conundrum, too much exercise will harm them but too little will also harm them. (Dr. Lucinda Batemen, Dr. Nancy Klimas). Programs based on a researched understanding of a ME/CFS patients physiological response to exercise and develop programs that include principles of energy conservation, pacing, activity management, monitoring of physiology into a comprehensive "whole of life" exercise programs. In the first instance, many patients need to reduce their activities of daily living and incidental or programmed "exercise". ( insert- Snell conceptual model diagram -).

For instance the work of the Workwell Foundation has helped people with ME/CFS improve their quality of life by pacing/resting and doing restorative exercise, using continuos heart rate monitoring as a guide. Patients are advised to stay below their anerobic threshold at all times and to breaks tasks into to small intervals ie 2 minutes or less so, as to stay under their anerobic threshold. The anerobic threshold may be determined by 2-day CPET test. The anerobic threshold is estimated as 55-60 % of your age predicted heart rate maximum ie 55-60% of 220-age. A third "guesstimate" is to run with keeping your heart rate under 100 bpm. Gentle restorative exercise is introduced slowly and as able without provoking symptoms and without causing post exertional exacerbation of symptoms. A stating point may be one or two deep belly breathes every second day, stretching or flexibility exercises in bed.

Workwell does not proclaim this as a cure but as a means of improving quality of life. The rate of increase is as tolerated but a year doing stretching and flexibility exercises on the bed is one example they quote, another is a woman becoming able to do a small amount of gardening after 3 years. Workwell recognise that any, additional activity is not suitable for the profoundly ill.

People wiht ME/CFS have a low anerobic threshold, often have orthostatic intolerance and their termperature drops after exertion. and documented dysfunctional responses to exertion (Snell et al and others listed in CCC and ICC). People with ME/CFS have "significantly impaired oxygen consumption levels suggest there may be an abnormal reliance on anerobic energy pathways during exercise and a low anerobic threshold (Snell et al). Hence,  exercises that would be aerobic for healthy individuals may be anerobic for people with ME/CFS and result in extreme fatigue and an exacerbation of their symptoms.

Patient Analysis of PACE Results
Graham McPhee and others created videos investigating the PACE trial data in relation to Graded Exercise Therapy.

Fear of exercise
The PACE trial investigators have stated that they believe a causal factor of the persistence of ME/CFS is fear of exercise. This claim as been criticized as unsupported by trial results.

Criticism
In 2010 at the Invest in ME Conference Doctor Paul Cheney said "The whole idea that you can take a disease like this and exercise your way to health is foolishness. It is insane".

Notable studies

 * 2016, Exercise therapy for chronic fatigue syndrome (Lillebeth Larun, Kjetil G. Brurberg, Jan Odgaard-Jensen, Jonathan R Price)
 * 2016, Neurocognitive improvements after best-practice intervention for chronic fatigue syndrome: Preliminary evidence of divergence between objective indices and subjective perceptions. (Cvejic E, Lloyd AR, Vollmer-Conna U)
 * 2009, A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS (Frank Twisk)

Learn more

 * Wikipedia - Graded Exercise Therapy"
 * NHS Graded Exercise Therapy Booklet - A self-help guide for those with chronic fatigue syndrome/myalgic encephalomyelitis (pdf)