Graded exercise therapy (GET) as a treatment principle for chronic fatigue syndrome may not only be ineffective, it could actually be harmful and unsafe!
One of the most common recommendations given to those with chronic fatigue syndrome is something called graded exercise therapy. Finally, research supports what those with CFS have been saying all along – graded exercise therapy doesn’t work. And it may actually make CFS worse.
Graded exercise therapy is a form of intervention that employs physical activity as its main method of treatment for chronic fatigue syndrome. In graded exercise therapy (GET), physical activity is introduced gradually, often in the form of gentle stretching, with a duration of as little as 5 min per day for individuals who have been physically inactive owing to their fatigue. (1)
As the patient gains strength, the intensity of physical exertion is increased over time. This form of therapy is highly controlled, and to be done correctly, it has to be followed according to a strict, balanced exercise plan, which includes mandatory periods of rest.
The main aim is not to overexercise and not to push the body to its limits, which would be detrimental to the patient’s health. If the physician and the patient manage to develop a suitable plan of physical activity, this can be effective in alleviating the burdens of disturbed sleep, low mood, pain, and other symptoms related to chronic fatigue, allowing the patient to improve the quality of life (2) – or so they say!
In theory, GET sounds as though it should work. It makes a great deal of sense. But those with chronic fatigue kept saying it didn’t work. Doctors pushed back saying research supports the effectiveness of graded exercise therapy and continued to prescribe it.
Divides and broken relationships between doctors and patients with CFS ensued. Each party thought the other was misinformed. Fortunately, research finally caught up. What chronic fatigue sufferers had been saying for years (“graded exercise therapy doesn’t work!“) is finally supported by the evidence.
And it turns out the researcher’s behind graded exercise therapy group are subject to a number of conflicting interests. Interests that may not be aligned with your well being.
Why is graded exercise therapy recommended for chronic fatigue syndrome?
Graded exercise therapy got its toe-hold in the world of chronic fatigue after a 2011 study (the PACE study). This was a UK-based study that aimed to test the efficacy of GET and cognitive behavioral therapy (CBT) on chronic fatigue. At the time, the PACE study was the largest of its kind and thought to be the most comprehensive. The results were published in a prestigious medical journal called The Lancet.
What exactly were the results?
Quoted from the study itself:
CBT (cognitive behavioural therapy) and GET (graded exercise therapy) can safely be added to specialist medical care to moderately improve outcomes for chronic fatigue syndrome. (3)
And so GET became the go-to recommendation for all of those with chronic fatigue. Doctors finally had an effective treatment protocol. They would help their patients overcome fatigue.
But there was a very important part of the puzzle that was (conveniently) overlooked – patients that were prescribed GET reported that it didn’t work. Time and time again, CFS patients reported a worsening of their symptoms. But doctors kept referring back to the PACE study and recommending graded exercise therapy.
Clearly, something was amiss…
A closer look at the PACE study
Upon closer inspection, the PACE study was found to be fraught with errors and reporting bias. Participants were said to have experienced an improvement in fatigue-related symptoms at 2-weeks and 52-weeks after treatment.
Sounds like the combination of GET and CBT was effective, right?
A follow-up study was done 2.5 years after the PACE study. It found that there were zero long-term improvements between GET/CBT and the control group. (4) The improvement(s) CFS patients experienced at weeks 2 and 52 of the trial all disappeared. Graded exercise therapy (over the long-term) did not improve fatigue symptoms nor quality of life outcomes. (5)
Additionally, the reporting methods used in the PACE study were widely criticized. To determine whether (or not) graded exercise therapy was successful in the treatment of chronic fatigue syndrome, patients were considered “recovered” if they obtained a specified threshold score on the fatigue and physical function self-report scales.
If a patient-rated their health as “much better” or “very much better“, they were considered a treatment success. (6) This simple one-time questionnaire type of evaluation is a far cry from the scientific method of inquiry. As I’m sure you know, your energy levels fluctuate day-to-day and hour-to-hour. There are normal rhythms of fatigue and energy that all of us experience in a given day.
The improvement in your energy that will be reported will be entirely dependent on how you’re feeling in the moment that I ask you the question. Imagine I ask you how your energy level is after you wake up from a terrible night’s sleep. You’ll report that you have low energy levels. Comparatively, if I ask you about your energy levels at the time of day when you feel the best, you’ll likely report a positive change.
This style of evaluation is effectively useless. It provides no solid data on the improvement (or lack thereof) from any participant in the PACE study. To further worsen the PACE study’s credibility, if participants failed to meet the author’s definition of chronic fatigue, then they were reported to have been improved. (7)
Is graded exercise therapy safe?
The PACE study classified graded exercise therapy as safe so long as: (8)
- You didn’t die,
- You didn’t experience a life-threatening illness,
- You weren’t hospitalized,
- You didn’t have a severe disability for at least 4-weeks,
- You didn’t inflict self-harm.
The PACE study concluded that graded exercise therapy was safe because only 1% of participants in the study experienced the above. I don’t know about you, but I would define safe with much more robust criteria than not dying. Fortunately, more studies were published that shed light on whether (or not) GET was safe.
Two additional studies done on graded exercise therapy found that it may not be as safe as originally thought. (9, 10) In one of these studies, 40% of participants experienced a worsening of their symptoms. (11) In the other study, nearly 70% of participants stopped participating in GET. (12)
I think it to be a safe assumption that if nearly 70% of your participants stop doing the recommended exercise(s) it’s probably because the exercise is either making their condition worse or not helping at all.
Research aside, what about all of the chronic fatigue sufferers personal anecdotes and questionnaires illustrating how graded exercise therapy worsened their condition? (13, 14, 15, 16, 17, 18, 19, 20, 21)
The myalgic encephalitis association found that 74% of patients experienced a worsening of their symptoms after graded exercise therapy. (22) And in 82% of patients whose fatigue was so bad that they were either house-bound or bed-ridden, graded exercise therapy worsened their condition. (23)
Perhaps most damning to the safety record of graded exercise therapy is that the protocols discourage participants from reporting an increase in their symptoms. Participants are told that a flaring of their symptoms is a “normal” response to exercise. (24)
In summary, graded exercise therapy is not safe for those with chronic fatigue. I recommend you avoid implementing GET protocols. Instead, find a knowledgeable functional medicine practitioner who can gently guide you back to health!
A modern look at GET in the treatment of chronic fatigue syndrome
In 2017, a systematic review of all the literature on graded exercise therapy’s effectiveness was done. (25) A review is a compilation of all the individual studies on a particular topic. Authors will then analyze all the results and (hopefully) come out with a clear picture as to whether a given modality is effective.
Patients with CFS may generally benefit and feel less fatigued following exercise therapy, and no evidence suggests that exercise therapy may worsen outcomes. (26)
You guessed it, more bias and poor reporting. Graded exercise therapy wasn’t dead yet. Fortunately, two reviews of this review were done in 2018. Both of which found that this 2017 paper was biased and that GET still didn’t work. (27, 28)
The 2018 reviews found that when the authors corrected the outcome measure, graded exercise therapy performed no better than the control group that received no treatment. (29) Perhaps more detrimental, those that report GET to be effective are researchers with a strong allegiance to GET. (30)
Conveniently, a study that strongly contradicted that GET was effective was left out of the 2017 review. This study clearly showed that graded exercise therapy did not benefit those with chronic fatigue syndrome. (31) This study also showed that GET worsened physical function and body pain scores.
It will probably take years before your family doctor is aware of this new data. In the interim, he/she will likely continue to recommend you follow a graded exercise program. You (likely) now know more than your doctor about what’s really going on with graded exercise therapy.
Bring this blog to your next doctor appointment. Show your doctor the new studies that clearly illustrate the ineffectiveness of graded exercise therapy. And whatever you do, avoid following a GET protocol. It will only make your fatigue worse!
What should you do in replace of GET?
Exertion (like that found in graded exercise therapy) worsens fatigue levels. If you’re just beginning your chronic fatigue recovery, don’t worry about exercise. Instead, focus what energy you have on your nutrition.
Your nutrition is the foundation of fatigue recovery. Until you get on an anti-fatigue nutrition plan, don’t worry about any other treatment recommendations. Nutrition is your first priority.
If you’ve already moved to fatigue-reset nutrition template, it’s time to take the next step – ketosis. A ketogenic diet increases your body’s ability to create ATP. And more ATP equates to more energy.
To overcome chronic fatigue, your diet needs to position you towards energy efficiency. The ketogenic diet does just that. For more information on the keto diet and chronic fatigue, click here.
In summary, ditch the graded exercise therapy. Focus your attention on your nutrition. Your energy levels will thank you!
Now, I want to hear from you!
What did GET do to your fatigue?
Also published on Medium.