N.I.C.E. Reinforces our Fatigue Management Programs! (But we may need a new job title…)

As Exercise Physiologists, we like to advocate for the benefits of exercise for almost every health condition under the sun (of course – exercise is in the name!).

But the use of exercise for chronic fatigue conditions is controversial. The initial recommendation for Graded Exercise Therapy as proposed by the PACE study in 2011 has received criticism from fatigue sufferers and specialists alike.

Post-exertional malaise is an experience all too common for this cohort – where even small levels of exertion (physical or mental) can result in significant and disabling fatigue that may last for days or even weeks. Just imagine being bed bound for a week because you hung out a load of washing, or took the dog for a 10 minute walk… Would you be jumping at the chance to sign up for an exercise program?!


Nice one, N.I.C.E.

The National Institute for Health and Care Excellence (N.I.C.E.) has recently updated their recommendations around the use of exercise therapy for fatigue recovery.

The verdict? Graded Exercise Therapy is out for chronic fatigue conditions. This led to questions from insurers…

 “You guys are our preferred fatigue provider… How can we still justify sending our Chronic Fatigue claimants to an EXERCISE specialist?!”

Luckily for Chronic Fatigue sufferers, we have more strings in our bow than purely ‘exercise’. We could spend hours coming up with alternate job titles to describe what we have to offer –  (we actually did this one team meeting!).

We’ve poured over the new N.I.C.E. guidelines and compared it with our approach. Needless to say, what we found was pleasing! Our holistic, lifestyle-based approach as EP’s closely reflects the extensive list of recommendations, including sleep, nutrition, stress, emotional wellbeing, and of course, activity management, suggested by N.I.C.E.

Rather than exclude us, the changes reinforce our rightful place, front and center in the fatigue management space.

The bottom line is, ‘exercise specialist’ or not, we know our way around a fatigue management program! Here is our specialist approach.


It’s about working within the individuals’ energy envelope.

Rather than talking about graded exercise programs, we think in terms of graded activity programs.

Many chronic fatigue sufferers struggle to complete the simple tasks required everyday – things like climbing stairs in their house, folding washing, cooking dinner, going out to the shops for food.

Activity is required to survive, and activity cannot be avoided altogether.  These everyday tasks must continue, even in the midst of a chronic fatigue condition. But the level of physical exertion must also be carefully managed.


What does a graded activity program provide? 

A graded activity program starts with education – Education around energy management and why it is important, the consequences of over-expending and strategies to better conserve energy. Often, activity must first be reduced before it can be increased.

These strategies may include aspects such as activity planning, pacing, breaking up activities with rest periods, task rotation, weekly time structuring and smoothing out ‘boom and bust’ patterns. (Of course, sleep is important when it comes to fatigue – so bring on a bit of sleep hygiene education too!)

Graded activity programs are specific to that individual and their unique energy envelope. Only when the envelope increases can the activity dose also increase – and only then in very measured, incremental changes.

“Physical maintenance” exercises are also recommended by N.I.C.E. for mobility, flexibility, posture, strength and endurance – but this is only after they have demonstrated tolerance for everyday activities. Activity management comes first and even then exercise should be implemented only within a closely supervised and highly personalised setting.


A Flexible Approach

Above all, the N.I.C.E. recommendations call for a collaborative approach between the patient and the therapist. Increasing activity levels must be a joint decision!  The patient is the best judge of their limits – they are, after all, the one living within it.

This means that the program needs to be flexible, taking into account the individual’s fatigue symptoms and adapting as needed to work within their unique energy envelope at the time. With variable and fluctuating levels of fatigue, the program may need to progress and regress on a day-to-day basis.


Sometimes, we need tools….

It can be hard to objectively quantify activity. Is a walk to the letterbox more or less exerting than folding the washing? Does cooking dinner affect fatigue more than an hour at the computer?

This is where technology can play a part. We will often suggest either a simple activity tracker watch which breaks down energy expenditure over the day, or a more comprehensive Heart Rate Variability tracker, which analyses heart rate data to provide a daily fatigue index. For more information on HRV, check out our article ‘The Secret Weapon: HRV’.

When coupled with an activity diary, the mist clears! Objectively tracking fatigue versus activity over the course of the program helps us to identify the biggest fatigue triggers, and teach our clients how to manage them. 


Make EP your first choice when it comes to fatigue management.

Have we convinced you yet?

Exercise Physiologists are not just personal trainers – they have specialist training in using personalised ACTIVITY programs (…and okay… sometimes exercise) to manage chronic health conditions.

Maybe we should call ourselves activity management specialists? Human movement experts? Health scientists?


Do you have a Chronic Fatigue client who may benefit from the assistance of an Exercise Physiologist?

Refer to the Specialised Health team!

* The PACE study received so much backlash that the researchers were forced to reanalyse the results of their data! 


  1. https://www.bmj.com/content/371/bmj.m4356
  2. https://www.nice.org.uk/guidance/GID-NG10091/documents/draft-guideline
  3. https://www.theguardian.com/society/2020/nov/10/fatigue-syndrome-exercise-therapy-loses-nice-recommendation
Author: Yolanda van Vugt

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