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Early in my illness, when I was still clinging to the idea of exercise, I applied to the Nuffield Health Long COVID rehabilitation program. At the time, I was largely bedbound, yet I was accepted into the program. I became hopeful, thinking, They must have the expertise to truly help.
The program included fatigue management resources, wellbeing support, one-on-one coaching, and both online and in-person group exercise sessions. The emotional support from the coach and the group was invaluable. However, the exercise component—while not strict Graded Exercise Therapy (GET)—progressed far too quickly and seemed to be adapted from a generic rehabilitation model.
Because it was a free program, I felt obligated to attend the sessions, even when it was clearly too much for my body. One incident stands out vividly. On one of my worst days, I was so unwell I couldn’t leave my bed. Still, I forced myself to get a taxi to the session, where we did exercises like walking lunges and jogging across the studio. Half an hour earlier, I had been horizontal. Unsurprisingly, I experienced a significant post-exertional malaise (PEM) flare afterward—a crash that left me even more debilitated.
What’s worse, I wasn’t alone. Everyone in my group experienced PEM from the program. The textbook fatigue management strategies we were given only made me focus on my symptoms more, adding another layer of frustration.
So why is GET so problematic for people with energy-deficient conditions like Long COVID and Chronic Fatigue Syndrome (CFS)? Let’s unpack this by first understanding what Graded Exercise Therapy is.
What Is Graded Exercise Therapy?
Graded Exercise Therapy is a rehabilitation approach designed to gradually increase physical activity levels over time. It’s traditionally used to improve overall function and reduce symptoms in people recovering from various conditions, including cancer, strokes, heart attacks, fibromyalgia, and CFS. However, its application in CFS is now under significant scrutiny due to its parallels with Long COVID.
On paper, this sounds logical. But for people with Long COVID or CFS, it often backfires. Instead of aiding recovery, GET can worsen symptoms, especially if applied rigidly or without consideration of the unique challenges of energy-deficient conditions.
Historically, GET has been prescribed as a one-size-fits-all solution for fatigue-related conditions. However, this approach is deeply flawed for several reasons:
Doesn’t Consider the Type of Movement. Not all movement is equal. For someone with Long COVID or CFS, the type of movement matters as much as the amount. Activities like jogging or compound exercises such as lunges may trigger PEM, while gentler, more controlled movements are often better tolerated.
One-Size-Fits-All Approach. GET often lacks personalization. It doesn’t account for individual variability in symptoms, daily energy levels, or overall capacity. While this is a generalization, it reflects how I’ve experienced it and seen it applied.
Prescribed Too Early. GET is sometimes introduced when a person’s body isn’t ready for progressive (or any level of) exercise, leading to crashes that can set recovery back significantly.
Rigid Structure. Recovery isn’t linear, and any program designed for energy-deficient conditions must account for fluctuations due to factors like stress, the menstrual cycle, and overall activity levels. GET’s inflexibility can lead to a mismatch between what the body needs and what the program demands.
Why Is This a Problem for Long COVID?
Living with an energy-limiting condition means walking a fine line between doing too little and doing too much. PEM—the hallmark symptom of these conditions—means that even small amounts of overexertion can lead to days or weeks of debilitating symptoms. A rigid program like GET often forces individuals into this exact trap, pushing them beyond their limits and triggering repeated crashes.
Recovery isn’t linear for people with Long COVID or CFS. What works one day may not work the next, and progress often looks more like a spiral than a straight line. Programs like GET fail to honor these realities.
How to exercise with long covid instead
If GET doesn’t work, what does?
Start Low and Go Slow. Begin with extremely low-intensity and low-volume movements appropriate to your stage of recovery and current energy levels. Think of gentle stretches and floor-based isolation exercises designed to activate specific muscle groups without overloading your system. (You can read more about why isolation exercises are ideal for recovery in [Rebuilding Strength: The Best Exercises for Long COVID and CFS Recovery].)
Prioritize Flexibility. A recovery program should adapt to your daily energy levels, stress, sleep, and overall movement load. It’s okay to scale back—or skip movement altogether—if your body isn’t ready or you need to prioritize rest.
Focus on Restorative Practices. Instead of pushing your limits, incorporate activities that restore energy. This might include mindfulness, grounding techniques, or diaphragmatic breathing exercises.
Work with a Specialist. Seek out professionals who understand energy-limiting conditions and the importance of pacing. They should help you follow a program that supports recovery without triggering PEM.
The Bottom Line
For those of us living with Long COVID or CFS, the traditional approach of Graded Exercise Therapy isn’t just unhelpful—it can be harmful. A movement plan that ignores the body’s daily ups and downs, forces linear progress, and pushes physical boundaries too soon is destined to fail.
The key to real progress lies in flexibility, patience, and truly listening to your body so you can find a level of consistency that allows you to gradually rebuild exercise tolerance. Recovery may take time, but with the right approach, it’s possible to regain strength without sacrificing well-being.
P.S. When you are ready. Here are two ways I can help you:
The Baseline Club. Affordable monthly coaching, to help you perform deliberate movement consistently and safely build back your exercise tolerance, keeping your muscles and joints healthy as you heal from long COVID or chronic illness. Learn more.
90 Day The Rebound Method. A unique reconditioning program for those no longer experiencing PEM and are ready to train back. You'll build back better than before with rock solid foundations, recover your exercise confidence and prevent injury. Take a closer look.
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