Graded exercise therapy

Graded exercise therapy (GET) is a controversial[1][2][3] intervention technique that proposes physical activity as the principal treatment method for addressing the symptoms of chronic fatigue syndrome. It promotes engagement in a program of physical activity that starts very slowly and gradually increases over time.

Graded exercise therapy
Other namesGET

This approach was originally proposed as part of a treatment plan for chronic fatigue syndrome (CFS), also referred to as myalgic encephalomyelitis (ME), and claims to avoid the extremes of the "push-crash" cycle of over-exercising during remittance or not exercising at all due to concern of relapse. Typically the GET program begins with active stretching, followed by range-of-motion contractions and extensions, done for five minutes per day for a completely inactive individual. Avoiding extremes is key, and activity must be balanced with rest. Exercise sessions are preset by the number of repetitions or amount of time, which are to be increased gradually over time. The duration is to be determined by the patient using trial and error, with the goal of stopping before becoming tired.

Evidence

According to the National Institute for Health Care and Excellence and the Mayo Clinic consensus recommendations for the treatment of ME/CFS, GET studies are of poor or very poor quality because of their methodology, inadequate tracking of harms, and a disease theory that conflicts with the evidence of multisystem biologic impairment.[2] The largest study on GET, the 2011 PACE trial, reported that GET and Cognitive Behaviour Therapy were safe and resulted in recovery for 22% of participants and improvement for 60%. However, outcome measures were modified midtrial without a clear rationale.[4] When the data were reanalyzed utilising the original protocol, the rate of improvement was reduced by a factor of three, and recovery rates decreased to 4% for GET, not significantly different from controls.[4] According to the US Agency for Healthcare Research and Quality, many of the studies on GET used dignostic criteria that could have included participants with other conditions than ME/CFS and found little or no evidence of efficacy once these studies were excluded from the analysis.[3] Moreover, contradicting safety claims, 54% to 74% of patients have reported experiencing harms after GET.[5]

Support and opposition

Because of the concerns over the quality of supporting evidence in favour of GET, the US Centers for Disease Control and Prevention and the United Kingdom's National Institute for Health and Care Excellence (NICE) have removed Graded Exercise Therapy from their recommended treatments for patients with chronic fatigue syndrome, with the NICE guidelines now stating that clinicians should not prescribe "any programme that ... uses fixed incremental increases in physical activity or exercise, for example, graded exercise therapy."[6][7]

According to the Mayo Clinic consensus recommendations for the treatment of ME/CFS, GET is an outdated standard of care that can worsen the condition.[2]

The patient group ME Association's position statement asserts that GET causes adverse reactions in a significant percentage of patients.[8]

Some prominent health organisations, such as the Royal Australian College of General Practitioners, still support the usefulness of GET for chronic fatigue syndrome.[9]

References
  1. NHS's "Treating chronic fatigue syndrome"
  2. Bateman, Lucinda; Bested, Alison C.; Bonilla, Hector F.; Chheda, Bela V.; Chu, Lily; Curtin, Jennifer M.; Dempsey, Tania T.; Dimmock, Mary E.; Dowell, Theresa G.; Felsenstein, Donna; Kaufman, David L. (2021-11-01). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management". Mayo Clinic Proceedings. 96 (11): 2861–2878. doi:10.1016/j.mayocp.2021.07.004. ISSN 0025-6196. PMID 34454716. S2CID 237419583.
  3. US Agency for Healthcare Research and Quality Diagnosis and treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Evidence Report/Technology Assessment No. 219. AHRQ Pub. No. 15-E001-EF. December 2014. Addendum July 2016. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/chronic-fatigue_research.pdf
  4. Wilshire, Carolyn E.; Kindlon, Tom; Courtney, Robert; Matthees, Alem; Tuller, David; Geraghty, Keith; Levin, Bruce (2018-03-22). "Rethinking the treatment of chronic fatigue syndrome-a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT". BMC Psychology. 6 (1): 6. doi:10.1186/s40359-018-0218-3. ISSN 2050-7283. PMC 5863477. PMID 29562932.
  5. Geraghty, Keith; Hann, Mark; Kurtev, Stoyan (September 2019). "Myalgic encephalomyelitis/chronic fatigue syndrome patients' reports of symptom changes following cognitive behavioural therapy, graded exercise therapy and pacing treatments: Analysis of a primary survey compared with secondary surveys". Journal of Health Psychology. 24 (10): 1318–1333. doi:10.1177/1359105317726152. ISSN 1461-7277. PMID 28847166. S2CID 35251525.
  6. US Centers for Disease Control and Prevention Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). November 19, 2019. https://www.cdc.gov/me-cfs/treatment/index.html
  7. "Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management | Guidance | NICE". www.nice.org.uk.
  8. ME Association's position on graded exercise therapy
  9. Royal Australian College of General Practitioners's "Graded exercise therapy: chronic fatigue syndrome"
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