Graded Exercise Therapy (GET)


What is graded exercise therapy?


Graded Exercise Therapy (GET) is one of the two treatments (the other one is Cognitive Behavioural Therapy) recommended by the National Institute for Health and Care Excellence (NICE) of the United Kingdom [1], as those which must be provided to individuals with mild or moderate Chronic Fatigue syndrome / myalgic Encephalomyelitis (CFS / ME). Currently, they are the interventions for which benefits are clearly found. In various diseases that present fatigue, such as stroke, rheumatoid arthritis, multiple sclerosis, cancer and others, treatment with graded endurance exercise has been found to help reduce fatigue [2-7].


GET uses regular exercise and physical activity, in order to help people who feel fatigued improve their physical condition and cope with the activities of daily living, with less difficulty. Techniques based on treatment protocol [8] to address the limitations in CFS are used. GET starts with a few activities, which progressively increased without increasing the symptoms. The program includes a series of methodical steps to achieve the goals set jointly by the therapist and the patient [5,6,8].


During GET the individual needs of each patient and their preferences are taken into account. According to the National Institute for Health and Care Excellence (NICE) [1], communication with the patients must be accompanied by documented written information tailored to the needs of the individual.

Among the general principles of care and treatment of the patients are:

  • Joint decision-making between the person with CFS / ME or fatigue from other causes and the health professional throughout all stages of treatment,

  • recognition and understanding by the health care professional of the impact of the situation and the symptoms on the patient,

  • provide information about CFS / ME and the possible causes, nature and course of the disease,

  • provide information on return to work or education. The therapist should advise on the suitability for work and education, proposing necessary adjustments to help patients return to these activities when they are ready and healthy enough,

  • for an effective treatment good communication between health professionals and people with CFS / ME and their carers, if they exist, is essential,

  • an individualised, person centred program should be offered to people with CFS / ME or fatigue from other causes, the purpose of which is:

    • the maintenance or gradual increase of the physical, emotional and cognitive capacity of the individual,

    • the management of the physical and emotional severity of their symptoms.


During GET, goals and targets for designing the overall management of fatigue are essential to be made. The pace of progress, throughout the course, should be agreed between the parties involved in the treatment. Under the guidance of the National Institute for Health and Care Excellence (NICE) of the United Kingdom [1] health professionals involved in the care of people with CFS / ME should have appropriate training and experience in this situation. The advice given to patients to exercise without supervision or without structure and vigorous exercise (like “just go to the gym” or “exercising more”) should not be given, because it can worsen the symptoms [1].


GET is usually given for 12 to 16 sessions and can be done in the form of individual therapy or group therapy. The advancement of technology has brought to the forefront the telerehabilitation, which has the benefit of monitoring patients who for some reason cannot present at the treatment centre of their specialist practitioner.



  1. NICE, Clinical Guideline 53. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy). Diagnosis and management of CFS/ME in adults and children, 2007.

  2. Andreasen et al. The effect of exercise therapy on fatigue in multiple sclerosis. Multiple Sclerosis Journal , 17(9);1041–1054.

  3. Heine et al. Exercise therapy for fatigue in multiple sclerosis. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD009956.

  4. Rongen – van – Dartel et al. Effect of Aerobic Exercise Training on Fatigue in Rheumatoid Arthritis: A Meta-Analysis. Arthritis Care & Research, 2015;67(8):1054–1062.

  5. Sharpe et al. Rehabilitative treatments for chronic fatigue syndrome: A long-term follow-up from the PACE trial. Lancet, 2015;2(12):1067-74. 

  6. White P, Goldsmith K, Johnson A, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011; 377: 823–36. 

  7. Zedlitz et al. Cognitive and Graded Activity Training Can Alleviate Persistent Fatigue After Stroke A Randomized, Controlled Trial. Stroke,2012;43:1046-1051.

  8. White et al. Protocol for the PACE trial: A randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or Εncephalopathy. BMC Neurology 2007, 7:6