Graded Exercise Therapy: How to Make It Very 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

Man gets chest pain during exercise Graded exercise therapy (GET) is physical exercise program that increases 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 by 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 their exercise for 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?

Effects of graded exercise therapy

Man running on beach Brain oxygen levels for normal breathing and deep breathing Since over 95% of modern people exercise with mouth breathing and believe that breathing more is good, it is clear that such 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 utilization of nitric oxide (produced in sinuses) and increases alveolar CO2 that improves oxygen transport profoundly improving biochemistry of the human body and decreasing hear 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 production of free radicals, chronic inflammatory response, and over-expression of hypoxia inducible factor-1. For more details, visit Effects of Exercise on the Respiratory System (see the link below).

Medical people smiling 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 (fibromyalgia or chronic fatigue) 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 Oxygen Levels: How brain and body oxygenation influence cardiovascular endurance, desire to exercise, fitness-related lifestyle factors and physical health
- Physical Health: 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
- How to Build More Body Muscle with Less Diet Protein: Bodybuilding requires less protein in 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.

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 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 Web Pages: Breathing norms, Medical Graphs and Tables about Breathing Rates (Minute Ventilation) and Body Oxygen in Healthy, Normal and Sick People
Breathing norms Parameters, graph, and description of the normal breathing pattern
6 breathing myths 6 myths about breathing and body oxygenation (prevalence: over 90%)
Hyperventilation Definitions of hyperventilation: their advantages and weak points
Hyperventilation Syndrome in the Sick. Table 1. Western scientific evidence about prevalence of CHV (chronic hyperventilation) in patients with various chronic conditions (34 medical studies)
Normal Minute Ventilation in Healthy Subjects: Easy and Light Breathing (14 Studies)
Hyperventilation Prevalence Present in Over 90% of Normal People (24 medical publications)
HV and hypoxia How and why deep breathing reduces oxygenation of cells and tissues of all vital organs
Body oxygen test How to measure your own breathing and body oxygenation (a simple DIY test)
Body oxygen in healthy Table 4. CP (body oxygen level) in healthy people (27 medical studies)
Body oxygen in sick Table 5. CP (body oxygen level) in sick people (14 medical studies)
Buteyko Table of Health Zones with clinical description of most common zones
Morning HV Morning hyperventilation effect or how and why critically ill people are most likely to die during early morning hours

References: CO2 Effects Web Pages
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 and oxygen transport are controlled by alveolar CO2 and breathing
Oxygen Transport depends on breathing and these two effects (Vasoconstriction-Vasodilation and the Bohr effect) are parts of two diagrams that summarize influences of hypocapnia (low CO2 content in the blood and cells) on circulation and O2 delivery
Free Radical Generation takes place due to anaerobic cell respiration caused by cell hypoxia. Hence, antioxidant defenses of the human body are also regulated by CO2 and breathing
Inflammatory Response is controlled by breathing since hypoxia leads to or intensifies chronic inflammation through over-expression of the hypoxia-inducible factor 1, while normal breathing reduces these processes
Nerve stabilization takes place due to calmative or sedative effects of carbon dioxide in neurons or nerve cells
Muscle relaxation or relaxation of muscle cells is normal at high CO2, while hypocapnia causes muscular tension, poor posture and, sometimes, aggression and violence
Brochodilation - dilation of airways (bronchi and bronchioles) by carbon dioxide, and their constriction due to hypocapnia
Blood pH regulation and regulation of other bodily fluids
CO2: Lung Damage Healer: Elevated carbon dioxide prevents injury and promotes healing of lung tissues
CO2: Skin and Tissue Healer
Synthesis of Glutamine in the Brain, CO2 fixation, and other chemical reactions
CO2 myth "CO2 is a toxic waste gas" myth
Breathing control How is our breathing regulated? Why hypocapnia makes breathing uneven 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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