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Pacing Is Not a Training Program: Why Confusing It With "Graded Exercise Therapy" Can Be Dangerous

Pacing is often mistaken for gentle graded training. Why that mix-up can be harmful and what pacing for ME/CFS actually means.

People who are new to pacing often hear well-meaning but risky advice: "Just increase your activity slowly and steadily, and your body will get used to it." That sounds reasonable – but for ME/CFS, long-COVID fatigue and related conditions involving post-exertional malaise (PEM), it is the exact opposite of pacing. This article focuses on a single but crucial aspect: the confusion between pacing and so-called Graded Exercise Therapy (GET) – and why this mix-up pushes so many beginners into a crash.

Two concepts that are often thrown together

Graded Exercise Therapy was recommended as a standard treatment for ME/CFS for years. The principle: you establish a baseline level of activity and then increase movement or activity in fixed, usually time-based steps – regardless of how symptoms develop. In this guideline, graded exercise therapy is defined as establishing a baseline of achievable exercise or physical activity and then making fixed incremental increases in the time spent being physically active. This rigid "more, no matter how you feel" logic is exactly what distinguishes GET from pacing, where the activity level is guided by actual symptoms.

This distinction is not an academic nuance. It led to one of the most remarkable reversals in the treatment history of a chronic illness: in 2007 NICE produced the first guideline for CFS/ME which recommended two forms of rehabilitation to help those with CFS/ME: Graded Exercise Therapy (GET) and Cognitive Behavioural Therapy (CBT). In 2021 NICE reviewed the scientific evidence, concluding the strength of evidence of benefit from both CBT and GET was low or very low, and also concluded that GET was unsafe. Instead of CBT and GET, the new guideline recommended energy management (pacing) which provides advice on how to live with the illness, making best use of energy without making symptoms worse.

The US health authority CDC now also explicitly warns against treating ME/CFS like ordinary deconditioning: vigorous aerobic exercise can benefit people with many chronic illnesses, but people with ME/CFS do not tolerate such exercise routines, and standard exercise recommendations for healthy people can be harmful for patients with ME/CFS.

Why this mix-up pushes so many people into a crash

The core medical reason lies in PEM: unlike deconditioning, ME/CFS and related conditions respond to exertion with a delayed worsening that can last for days. A fixed escalation schedule like GET systematically ignores that signal, because activity keeps increasing regardless of what the body reports back.

Patient surveys from several countries show just how real this risk is. A large Australian survey found a clear result: Emerge Australia's 2018 Health and Welfare Survey found that 89% of the 610 respondents indicated that increasing their level of exercise/activity resulted in a worsening of their symptoms. Such findings have been confirmed repeatedly and independently, which is a key reason professional bodies now word their guidance far more cautiously. The UK's ME Association summarises the current position this way: graded exercise therapy (GET) should not be prescribed to people with ME/CFS because there is no sound evidence of efficacy and there is also extensive patient evidence that GET can cause serious harm.

Three common beginner mistakes that stem from this confusion

People learning pacing for the first time often unconsciously carry over thought patterns from a training context. Three patterns come up especially often:

  • The fixed escalation plan: "10 minutes of walking this week, 15 next week" – regardless of how the body reacts. This is essentially GET logic, not pacing. Pacing follows symptoms, not a calendar.
  • Good days as a free pass: On a better day, people try to catch up on everything they missed on bad days – often well beyond their usual level. This can trigger exactly the delayed crash pacing is meant to prevent.
  • Pacing as a "motivation issue": The idea that you just need to push through and do a bit more to "get back into it." With PEM, this is not a motivation problem but a physiological signal that should be taken seriously.

What pacing means instead

At its core, pacing is not an escalation program but an adjustment of activity to what the body can actually handle on a given day – sometimes more, often less – with the goal of avoiding PEM episodes as much as possible. Effective pacing encourages patients to be as active as possible within the limits of their symptoms, also known as their energy envelope. This energy envelope is not a fixed quota to be expanded week by week, but a flexible framework that follows your current state.

Important: this article does not replace medical advice. Whether, how, and to what extent physical activity makes sense for you individually should be discussed with a healthcare professional experienced in ME/CFS, long COVID, or POTS – especially if you are unsure whether a worsening is related to PEM. mypacing can help you make your own patterns between activity and recovery more visible, but it is not a medical device and does not provide diagnoses or treatment recommendations.

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