Graded Exercise Therapy (GET) is a rehabilitation approach that involves slowly and gradually increasing physical activity over time, starting from a patient’s current abilities and systematically building up their capacity. It focuses on incremental challenges to an individual’s physical limits without exceeding them, aiming to prevent further injury or symptom exacerbation.
Understanding Graded Exercise Therapy
Graded Exercise Therapy operates on the principle of individualized pacing, balancing activity and rest to prevent overexertion while gradually increasing physical demands. The approach aims to address deconditioning, caused by prolonged inactivity and leading to a loss of fitness and strength. GET seeks to reverse this deconditioning and reduce associated symptoms.
A central theory behind GET is to reduce fear-avoidance behaviors, where individuals avoid activities due to pain or symptom flares. Gradual exposure to these activities can help build confidence and decrease anxiety related to movement. This systematic progression helps break cycles of inactivity and the “boom-bust” pattern, where periods of overexertion are followed by severe crashes. The goal is to improve muscle flexibility, strength, and overall fitness, allowing individuals to perform daily activities more comfortably.
Conditions Where Graded Exercise Therapy May Be Used
Graded Exercise Therapy has historically applied to conditions where deconditioning or fear of movement contributes to functional limitations. It has been considered for chronic low back pain, to improve pain management and promote a positive mindset towards physical activity. In post-surgical rehabilitation, GET can support a structured return to physical activity, to help patients regain strength and mobility.
GET has also been used for conditions like chronic fatigue syndrome (CFS), also known as Myalgic Encephalomyelitis (ME). While its suitability for ME/CFS is now highly debated, its historical application aimed to improve symptoms of fatigue and functional impairment by gradually increasing physical activity. GET’s effectiveness varies significantly among individuals, underscoring the importance of thorough patient assessment to determine its appropriateness.
Implementing Graded Exercise Therapy
Implementing Graded Exercise Therapy begins with a comprehensive initial assessment by a physiotherapist or exercise physiologist. This evaluation establishes current physical capabilities and helps negotiate realistic, functional goals. For instance, a patient might aim to manage household tasks or garden work more effectively, guiding the exercise plan.
Following the assessment, a personalized exercise plan is developed, often starting with activities like walking, jogging, or swimming. The program systematically increases session duration, typically by 10-20% every 1-2 weeks, until a target of around 30 minutes of light exercise five times a week is achieved. Once duration goals are met, exercise intensity may be gradually increased, perhaps by adding short bursts of higher intensity activity or increasing resistance on machines. Consistent monitoring is essential throughout the process, with adjustments made based on progress and symptom response. If symptoms worsen, increases may be paused until manageable, or activity level reduced.
Controversies and Important Considerations
Controversies surround Graded Exercise Therapy, particularly its application to Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Patient advocacy groups and individuals with ME/CFS have raised concerns about GET, reporting potential for symptom exacerbation or harm. They argue the underlying model for GET in ME/CFS, which suggests deconditioning and fear of activity as primary drivers, lacks sufficient evidence and contradicts patient experience.
The National Institute for Health and Care Excellence (NICE) in the UK removed its recommendation for GET for ME/CFS in 2021, citing reported harm and low quality evidence. This shift reflects an evolving understanding of ME/CFS as a complex biomedical condition, where pushing patients beyond physiological limits can trigger post-exertional malaise (PEM), a worsening of symptoms after minor exertion. For individuals with ME/CFS and Long COVID, research suggests physiological deficiencies limit aerobic capacity; GET may not improve this but instead cause harm. Therefore, current guidelines emphasize patient-centered, individualized care prioritizing symptom management and shared decision-making, exploring alternative or complementary therapies that do not risk worsening the condition.