Graded exercise therapy

Graded exercise therapy (GET) is a form of physical therapy for the treatment of chronic fatigue syndrome where physical activity is gradually increased over time. It is controversial because of evidence of abnormal responses to exercise in CFS patients. In the UK the term is used to define a particular type of graded exercise therapy based in the premise that the disease is a somatoform and medically unexplained syndrome.

The term graded exercise therapy is also used to refer to any exercise regime that increase over time. 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 I 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 or 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 slowly, improving quality of life. The rate of increase is as tolerated but a year doing stretching and flexibility exercises is one example, 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.

In Australia many doctors appear to use the term Graded Exercise Therapy much more broadly than the NICE/PACE trial definition used in the UK. Others use it in the manner used in the UK eg at some of the "fatigue" clinics. ME/CFS patients tend to regard GET as the NICE/PACE version.

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 Guidelienes were effective. The fact that the objective measures of success as found by the PACE trial authors were null, hasn't stopped the PACE trial authors from claiming the effectiveness of GET and CBT. Somehow the fact that people severely ill at the beginning of a trial are only slightly less severely ill at the end of the trial, as objectively measured by the 6 minute walking test, has been called a moderate recovery.

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 rare as healthy 80 year olds.

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)