Graded Exercise Therapy: How to Make It Safe and Effective

“All chronic pain, suffering and diseases are caused
from a lack of oxygen at the cell level."
Prof. A.C. Guyton, MD, The Textbook of Medical Physiology*

* World’s most widely used medical textbook of any kind
* World's best-selling physiology book

Graded exercise therapy (GET) is physical exercise program that increases the duration and intensity of exercise slowly and gradually. This clinical approach has been used for many decades for chronic fatigue syndrome (CFS), heart failure, chronic back pain, diabetes and many other conditions.

A typical program of graded exercise therapy starts with 5 minute walking every other day for 1 or 2 weeks. If the person feels improvement, he can add up to 5 more minutes to his exercise for the next 1 or 2 weeks.

Clinical trials of graded exercise therapy for chronic fatigue reported moderate improvement (Tench et al, 2005) or inconclusive results (Ridsdale et al, 2004). Furthermore, some reviews suggested that graded exercise therapy can be harmful for chronic fatigue patients (Twisk & Maes, 2009). Why do we have this confusion?

Over 150 Russian doctors tested thousands of their patients and found that physical exercise with mouth breathing is a great threat to health since it usually causes exacerbations of symptoms and feeling worse after exercise. These health professionals confirmed that exercise become safe and effective when the person has nose only breathing during physical exercise.

Effects of graded exercise therapy

Since over 98% of modern people exercise with mouth breathing and believe that breathing more is good, it is clear that such a graded exercise therapy will produce poor effects on brain and body oxygenation. Sick people are generally unable to get benefits from graded exercise therapy with oral breathing. In contrast, nose breathing allows the utilization of nitric oxide (produced in sinuses) and increases alveolar CO2 that improves oxygen transport profoundly improving biochemistry of the human body and decreasing one's heart rate.

If graded exercise therapy is done with strictly nasal breathing (in and out), patients can avoid the following negative after-effects of exercise with mouth breathing: anaerobic cellular respiration, elevated blood lactate, oxidative stress or the production of free radicals, chronic inflammatory response, and the over-expression of hypoxia inducible factor-1. For more details, visit the web page devoted to effects of exercise on the respiratory system (see the link below).

According to over 150 Russian MDs practicing the Buteyko breathing method in Russia, physical activity with nose breathing is safe even for sick people with chronic fatigue or fibromyalgia. It should be increased very gradually in order to be the central factor of graded exercise therapy that helps people to develop light and easy automatic breathing at rest (i.e., normal breathing) and increase body-oxygen levels.

Another finding of Russian doctors is that sick people with less than 20 s for the body-oxygen test (with fibromyalgia or chronic fatigue as well) cannot exercise rigorously with nose breathing (e.g., during running). Therefore, they should exercise easier and start with walking as an initial phase of their graded exercise therapy. With more than 20 s of oxygen in the body, people can start running with nose breathing in and out, as their final part of graded exercise therapy.

Web pages about cardiovascular endurance, physical exercise, running, body building, and sports:
- Cardiovascular endurance and body O2 levels: How brain and body oxygenation influence cardiovascular endurance, desire to exercise, fitness-related lifestyle factors and physical health
- Physical health: It is impossible without high body-oxygen levels since low tissue oxygenation promotes chronic fatigue, diseases and abnormal states of the mind
- Breathing techniques for running: Which breathing techniques provide maximum body oxygenation at rest and during running?
- Benefits of physical activity: The main benefits of correct physical activity for health are due to more oxygen in body cells. Learn how to exercise correctly to get maximum benefits from exercise and sports
- Benefits of running correctly include increased cell and body-oxygen levels provided that you run with nose breathing only (in and out) mimicking some effects of high-altitude training
- Effects of exercise on the respiratory system: They are short-term and long-term and mainly depend on your breathing route: mouth vs. nose breathing
- Effects of lifestyle factors on sport performance are individual, but they all relate to increased O2 levels in body cells
- How to build more body muscle with less diet protein: Bodybuilding does not require as much protein in one's diet to build muscles if the body cells are well oxygenated due to correct breathing 24/7
- Graded exercise therapy: How to Make It Very Effective: Graded exercise therapy can be very beneficial, if it is done with one old key rule: nose breathing only
- Training Mask: Most advanced forms of physical exercise to boost body oxygenation, VO2max, endurance, and health.

Short sport and fitness articles: Breathing at rest, cardiovascular endurance and sport performance:
- Simple breathing exercise for higher VO2max
- Changing VO2max by breathing differently at rest
- Exercise is joy only when the body is oxygenated at rest
- When exercise is 100% safe for chronic diseases
- Why modern man gets little, if any, benefits from exercise
- Which exercise parameters increase body oxygenation

Reference pages: Breathing norms and medical facts:
- Breathing norms: Parameters, graph, and description of the normal breathing pattern
- 6 breathing myths: Myths and superstitions about breathing and body oxygenation (prevalence: over 90%)
- Hyperventilation: Definitions of hyperventilation: their advantages and weak points
- Hyperventilation syndrome: Western scientific evidence about prevalence of chronic hyperventilation in patients with chronic conditions (37 medical studies)
- Normal minute ventilation: Small and slow breathing at rest is enjoyed by healthy subjects (14 studies)
- Hyperventilation prevalence: Present in over 90% of normal people (24 medical studies)
- HV and hypoxia: How and why deep breathing reduces oxygenation of cells and tissues of all vital organs
- Body-oxygen test (CP test) : How to measure your own breathing and body oxygenation (two in one) using a simple DIY test
- Body oxygen in healthy: Results for the body-oxygen test for healthy people (27 medical studies)
- Body oxygen in sick : Results for the body-oxygen test for sick people (14 medical studies)
- Buteyko Table of Health Zones: Clinical description and ranges for breathing zones: from the critically ill (severely sick) up to super healthy people with maximum possible body oxygenation
- Morning hyperventilation: Why people feel worse and critically ill people are most likely to die during early morning hours

References: pages about CO2 effect:
- Vasodilation: CO2 expands arteries and arterioles facilitating perfusion (or blood supply) to all vital organs
- The Bohr effect: How and why oxygen is released by red blood cells in tissues
- Cell oxygen levels: How alveolar CO2 influences oxygen transport
- Oxygen transport: O2 transport is controlled by vasoconstriction-vasodilation and the Bohr effects, both of which rely on CO2
- Free radical generation: Reactive oxygen species are produced within cells due to anaerobic cell respiration caused by cell hypoxia
- Inflammatory response: Chronic inflammation in fueled by the hypoxia-inducible factor 1, while normal breathing reduces and eliminates inflammation
- Nerve stabilization: People remain calm due to calmative or sedative effects of carbon dioxide in neurons or nerve cells
- Muscle relaxation: Relaxation of muscle cells is normal at high CO2, while hypocapnia causes muscular tension, poor posture and, sometimes, aggression and violence
- Bronchodilation: Dilation of airways (bronchi and bronchioles) is caused by carbon dioxide, and their constriction by hypocapnia (low CO2)
- Blood pH: Regulation of blood pH due to breathing and regulation of other bodily fluids
- CO2: lung damage: Elevated carbon dioxide prevents lung injury and promotes healing of lung tissues
- CO2: Topical carbon dioxide can heal skin and tissues
- Synthesis of glutamine in the brain, CO2 fixation, and other chemical reactions
- Deep breathing myth: Ignorant and naive people promote the idea that deep breathing and breathing more air at rest is beneficial for health
- Breathing control: How is our breathing regulated? Why hypocapnia makes breathing uneven, irregular and erratic.

References

Psychol Med. 2004 Jan;34(1):37-49.
Is graded exercise better than cognitive behavior therapy for fatigue? A UK randomized trial in primary care.
Ridsdale L, Darbishire L, Seed PT.
Department of Neurology, Guy's, King's and St Thomas's School of Medicine, London.
BACKGROUND: Patients frequently present with unexplained fatigue in primary care, but there have been few treatment trials in this context. We aimed to test cognitive behavior therapy (CBT) and graded exercise therapy (GET) for patients presenting to their family doctor with fatigue. Secondly, we described the outcome for a cohort of patients who presented to the same doctors with fatigue, who received standard care, plus a booklet...
... CONCLUSIONS: Short courses of GET were not superior to CBT for patients consulting with fatigue of over 3 months in primary care. CBT was easier 'to sell'. Low recovery in the CFS subgroup suggests that brief treatment is too short.

Rheumatology (Oxford). 2003 Sep;42(9):1050-4. Epub 2003 Apr 16.
Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise.
Tench CM, McCarthy J, McCurdie I, White PD, D'Cruz DP.
National Sports Medicine Institute, The London NHS Trust, London, UK.
... CONCLUSION: These findings support the use of appropriately prescribed graded aerobic exercise in the management of patients with fatigue and systemic lupus erythematosus.

Neuro Endocrinol Lett. 2009;30(3):284-99.
A review on cognitive behavioral therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS.
Twisk FN, Maes M.
ME-de-patiënten Foundation, Limmen, the Netherlands.

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