## Summary Graded exercise therapy (GET) is not recommended for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) due to evidence of harm, particularly the exacerbation of post-exertional malaise (PEM), as highlighted in updated clinical guidelines. ## Detailed Answer Graded exercise therapy (GET) is not recommended for individuals diagnosed with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). This stance is reflected in updated clinical guidance, including recommendations from NICE, which previously endorsed GET but has since revised its position^{[1, 13]}. The primary reason for this change is the recognition that GET can cause significant harm and adverse outcomes by worsening core symptoms, most notably post-exertional malaise (PEM), a defining characteristic of ME/CFS^{[11, 18]}. Evidence indicates that trials evaluating GET have exhibited methodological flaws and have not reliably restored patients' ability to work^{[7, 13]}. Current management strategies for ME/CFS focus on symptom management, pacing activities to avoid PEM, and providing appropriate support, rather than the principles of GET^{[1, 4]}. ## Clinical Pearls • Recognize post-exertional malaise (PEM) as a critical symptom of ME/CFS that Graded Exercise Therapy (GET) can significantly worsen^{^{[11, 18]}}. • Avoid prescribing GET, which involves structured, incremental increases in physical activity, as it is linked to adverse outcomes and symptom exacerbation in ME/CFS patients^{^{[1, 13, 18]}}. • Focus on patient-centered approaches to activity management and energy pacing to prevent PEM, aligning with updated ME/CFS guidelines that move away from GET principles^{^{[1, 4]}}.