Graded Exercise Therapy (GET): An Overview
Graded Exercise Therapy (GET) is an approach that gradually increases aerobic activity—such as walking or swimming—with the goal of “reconditioning” patients by progressively building their exercise tolerance. These activities rely on oxygen to produce energy through aerobic metabolism. However, as the intensity of exercise increases, the body eventually transitions to anaerobic metabolism—this shift is marked by the ventilatory/anaerobic threshold (V/AT).
The underlying idea of GET is that by slowly increasing both the duration and intensity of exercise, deconditioning can be reversed, leading to improved aerobic capacity, typically measured as VO₂ max. While this method may benefit some individuals, it does not work the same way for those with ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome) and long COVID.
Why GET May Be Harmful for Individuals with ME/CFS and Long COVID
Patients with ME/CFS and long COVID face unique physiological challenges that limit their aerobic capacity. Instead of enhancing VO₂ max, GET can actually cause harm. This inability to replicate performance indicates that exercise may further compromise the already fragile aerobic system in these patients, rather than improving it.
The Impact of Post-Exertional Malaise (PEM)
A critical factor in the adverse response to GET among ME/CFS and long COVID patients is post-exertional malaise (PEM).
PEM is characterized by a significant exacerbation of symptoms—such as profound fatigue, cognitive difficulties, and increased pain—following even minimal physical or mental exertion. When patients exceed their limited energy envelope, they often experience “crashes,” where their symptoms worsen dramatically after exercise.
This cycle of overexertion followed by a crash not only fails to improve aerobic capacity but can also lead to a continuous pattern of harm, trapping patients in a debilitating boom-bust cycle.
Alternative Approaches and Recommendations
In light of these findings, we strongly advise against using GET for individuals with ME/CFS and long COVID. Instead, a more tailored physical therapy approach is recommended—one that is supervised by healthcare professionals knowledgeable about the specific challenges of these conditions.
This alternative strategy focuses on avoiding the triggers that can lead to PEM by working within the patient’s energy limits and emphasizing anaerobic or analeptic exercise techniques rather than traditional aerobic exercises.
Collaborating with a physical therapist who understands the limitations associated with ME/CFS and long COVID is essential. Such a professional can help develop a safe and effective plan that minimizes the risk of triggering PEM and prevents further damage to the patient’s aerobic energy system.
This comprehensive overview highlights why GET, which aims to improve aerobic capacity through gradual exercise increases, may inadvertently worsen symptoms in ME/CFS and long COVID patients—primarily due to their unique susceptibility to PEM.