CPET – Cardiopulmonary Exercise Test

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Why Graded Exercise Therapy (GET) is Not the Answer for ME/CFS and Long COVID

Exercise is essential in preventing, treating, and rehabilitating many diseases. Research has repeatedly shown that physical activity improves quality of life and lifespan. It’s no wonder why most doctors encourage patients to do more. But is exercise good for everyone? 

While the health benefits are indisputable, there are some diseases for which exercise – as prescribed by many physicians – is harmful. Part I of this blog explores why graded exercise therapy (GET) is contraindicated in people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and long COVID. Part II will cover the controversy over prescribing GET as a treatment for ME/CFS and long COVID.

Understanding Graded Exercise Therapy

GET involves gradually increasing aerobic activity over time. The objective is to “recondition” ME/CFS patients by building tolerance to exercise.

Aerobic exercise produces energy by using oxygen. Examples include low to moderate-intensity activities, such as walking and swimming. As exercise intensity increases, the body shifts from aerobic (with oxygen) to anaerobic metabolism (without oxygen), which is referred to as the ventilatory/anaerobic threshold (V/AT). 

The concept of GET is that gradually increasing the amount and duration of exercise can overcome deconditioning by improving aerobic capacity, as measured by VO2 max. Read below why this approach does not work for people with ME/CFS and long COVID.

Why GET isn’t suitable for people with ME/CFS and long COVID

People with ME/CFS and long COVID have physiological deficiencies that place a limit on aerobic capacity. With these conditions, GET will not improve aerobic capacity (e.g., VO2 max) but instead may cause harm. 

Research by Workwell Foundation demonstrates why GET is ill-advised for people with ME/CFS and long COVID. People with these conditions tend to have a much lower than expected VO2 max and switch to anaerobic metabolism at very low activity thresholds. Using a two-day test-retest protocol involving cardiopulmonary exercise testing (CPET), patients are often unable to reproduce results on the second day of testing. This is a significant finding because it is not found in the majority of other chronic illnesses. 

The lack of reproducibility between the first and second tests shows that exercise worsens rather than improves aerobic capacity, as proponents of GET posit. This finding is thus far unique to ME/CFS and long COVID. 

People who exceed their energy envelope experience “crashes” after aerobic exercise. During a crash, patients have worsened symptoms, a phenomenon called post-exertional malaise (PEM). Unless patients pace their activities, they risk causing further damage to their aerobic system and can fall into a boom-bust cycle involving rolling PEM. 

Aerobic exercise makes people with ME/CFS and long COVID sicker, not better. 

Workwell Foundation recommends against GET for people with ME/CFS and long COVID.  Due to the inappropriate prescription of GET by a large number of healthcare professionals in mainstream medicine, Workwell created a letter opposing GET for patients to share with their doctors. 

Is all exercise harmful for ME/CFS and long COVID?

No. People with ME/CFS and long COVID can benefit from physical therapy as long as it is supervised by a medical professional who is knowledgeable of the harms associated with GET.  Appropriate physical therapy should be tailored to avoid the harmful effects of aerobic exercise – a concept called anaerobic or analeptic exercise. Finding a physical therapist who understands the limitations of ME/CFS is critical for averting further damage to the aerobic energy system.

Workwell Foundation is pleased to announce a new program called Workwell Health that seeks to connect patients who experience exercise intolerance with physical therapists who have the appropriate training to work with people with ME/CFS, long COVID, and other fatiguing conditions. Stay tuned for more information on this exciting new program! 

For more information about 2-day CPET, disability testing, and pacing activities using a heart rate monitor, please visit Workwell Foundation’s website

To schedule a 2-day CPET, please contact Workwell Foundation by phone at (661) 466-2545 or email: info@workwellfoundation.org.

 For a brochure describing our services, please click here.