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Graded Exercise as an Approach for Mental Health

Original Editor - Shaimaa Eldib Top Contributors - Farah Al Dweik, Angelos Spiliopoulos, Shaimaa Eldib, Kim Jackson, Tolulope Adeniji, Vidya Acharya, Amanda Ager and Rishika Babburu
==Page Under Review== This article is currently under review and may not be up to date. Please come back soon to see the finished work! (13/11/2026)

Introduction

Physical activity and structured exercise are increasingly recognised as important components of mental health care.[1][2] Recent systematic reviews have demonstrated that exercise can reduce symptoms of depression, anxiety and psychological distress.[2] Physiotherapists can support people experiencing mental health conditions through exercise programmes that improve physical fitness, support stress regulation, enhance sleep quality and self-confidence, and provide opportunities for social connection, potentially reducing feelings of loneliness.[3][4][5]

Definition

Graded exercise is a structured, individualised approach in which physical activity begins at a manageable level and is progressively adjusted according to a person's functional capacity, goals and response to exercise.[1][2][6]

Key principles include establishing a realistic starting level, setting meaningful goals, adjusting exercise intensity and duration, monitoring physical and psychological responses, and adapting progression according to individual needs.[6] Exercise progression should remain flexible, particularly when fatigue, fluctuating symptoms or other health conditions affect exercise tolerance.[6]

Graded Approaches in Rehabilitation

Graded exercise, graded activity and graded exposure use gradual progression but differ in their clinical objectives.[6][7][8][9] Graded exercise focuses on improving physical capacity, graded activity supports participation in daily activities, and graded exposure addresses fear and avoidance associated with specific movements or bodily sensations.[7][8][9]

Table 1. Comparison of Graded Exercise, Graded Activity, and Graded Exposure [7][8][9]

Approach Primary focus Clinical example
Graded exercise Improving physical capacity through structured exercise, with gradual adjustments to intensity, frequency or duration. A person experiencing depression and physical deconditioning starts with a 5-minute walk and gradually increases the duration according to their capacity and response.
Graded activity Improving functional participation through planned, achievable increases in daily activities. A person experiencing depression and reduced daily activity begins preparing one meal each day and gradually resumes other household tasks.
Graded exposure Reducing fear and avoidance through gradual engagement with feared movements, activities or bodily sensations. A person with anxiety who avoids exercise because of an increased heart rate gradually engages in activities that produce these sensations, with appropriate clinical support.

The clinical examples illustrate how each approach may be applied in mental health physiotherapy; they are not interventions directly evaluated in the cited studies.

In clinical practice, physiotherapists may combine these approaches according to individual needs. For example, a person experiencing anxiety and physical deconditioning may benefit from progressive exercise to improve physical capacity alongside exposure-based strategies to address fear of exercise-related bodily sensations.[6][9]

Graded Exposure for Pain Explained.[10]


Types of Exposure in Rehabilitation

Exposure-based interventions aim to reduce fear and avoidance by helping individuals gradually engage with feared bodily sensations or situations.[9][11] In mental health physiotherapy, these approaches may complement graded exercise when anxiety, fear of movement or avoidance interferes with physical activity participation.[9][11]

Interoceptive Exposure

Interoceptive exposure involves deliberately experiencing feared internal bodily sensations, such as increased heart rate, breathlessness, sweating or dizziness, within an appropriately controlled therapeutic setting.[9] It is commonly used in the treatment of panic-related symptoms to address catastrophic interpretations of bodily sensations and reduce avoidance.[9][11]

Education about the mind–body connection can help individuals understand how anxiety, autonomic arousal and the interpretation of bodily sensations influence their responses to physical activity.[9][12] Repeated exposure provides opportunities to learn that uncomfortable physiological sensations do not necessarily indicate danger and can be experienced without avoidance.[9][13] The aim is to increase tolerance of bodily sensations and reduce fear rather than eliminate normal physiological arousal.[12][13]

Clinical Example: A person experiencing panic symptoms may avoid walking uphill or exercising because an increased heart rate triggers fear of losing control.

Following appropriate medical screening, a physiotherapist working within their scope of practice and, where appropriate, alongside a mental health professional may apply the following steps based on exposure principles.[9][12]

  1. Identify feared sensations: Explore which bodily sensations trigger anxiety, how the person interprets them and which activities they avoid.[9][12]
  2. Provide education: Explain the relationship between physical activity, autonomic arousal, anxiety and normal physiological responses.[9][12]
  3. Select an appropriate activity: Introduce a manageable activity, such as brisk walking or stepping in place, that naturally produces the feared sensations within medically appropriate limits.[9]
  4. Practise exposure: Support the person in gradually experiencing and tolerating the feared sensations without immediately stopping the activity or attempting to suppress the sensations, while maintaining appropriate medical safety.[12][13]
  5. Reflect and progress: Discuss what the person expected to happen, what actually occurred and how their confidence and responses change through repeated practice.[12][13]

Exteroceptive Exposure

Exteroceptive exposure, commonly described as in vivo or situational exposure, involves gradually approaching feared external environments, activities or situations rather than avoiding them.[14] It aims to reduce avoidance and help individuals develop new learning about situations they perceive as threatening.[14][15][16]

Clinical Example: A person experiencing social anxiety may avoid exercising in a gym because they fear being observed or negatively judged by others.[14][16] The physiotherapist, in collaboration with a mental health professional where appropriate, can support gradual participation using exposure principles.[14][15]

  1. Identify feared situations: Explore the environments the person avoids and their expectations about what might happen.[14]
  2. Develop an exposure hierarchy: Collaboratively identify situations of varying difficulty, such as entering a gym, exercising near others or joining a group class.[15]
  3. Begin with an achievable activity: The person might initially visit a quiet gym before progressing to exercising in the presence of others.[15]
  4. Encourage new learning: Help the person compare their feared predictions with what actually happened during exposure.[14][15]
  5. Review participation: Monitor avoidance, confidence and progress towards meaningful physical activity goals.[14]

Desensitisation and Nervous System Regulation

Repeated exposure to feared situations or bodily sensations can reduce fear and avoidance through learning processes that include habituation and inhibitory learning.[13][14][15] However, contemporary exposure models emphasise learning that feared outcomes do not occur as expected, rather than requiring anxiety or physiological arousal to decrease during every session.[12][13][14]

Education about the relationship between anxiety, bodily sensations and perceived threat can help individuals recognise how normal physiological responses may become associated with fear.[11][13] During exposure, clinicians can support individuals in identifying feared predictions, experiencing sensations or situations within appropriate safety limits, and reflecting on the difference between anticipated and actual outcomes.[13][15]

Breathing and grounding strategies may support broader emotional regulation, but clinicians should consider whether using them specifically to prevent feared sensations could interfere with exposure-based learning.[13][12] The aim is not necessarily to calm the nervous system during each exposure, but to strengthen the individual's ability to tolerate physiological arousal and participate in meaningful activities despite discomfort.[16]

The term desensitisation should be used carefully because reduced fear of bodily sensations does not necessarily indicate a measurable reduction in physiological or sensory sensitivity.[13][14]

How Exercise Influences Mental Health

Physical exercise influences mental health through interconnected biological, psychological and social processes rather than a single mechanism.[17][18] These include adaptations in neural function, stress-response systems, physical health, emotional experiences, self-efficacy and social participation.[17][18] Understanding these processes can help physiotherapists explain the benefits of exercise, address barriers to participation and develop individualised rehabilitation programmes.[17][18]

Neurobiological and Physiological Effects

Neuroplasticity and Brain-Derived Neurotrophic Factor (BDNF)

Neuroplasticity is the nervous system's ability to change its structure, function and connectivity in response to experience, learning and environmental demands.[19] Exercise may influence neuroplasticity through neurotrophic signalling, synaptic adaptations, changes in cortical excitability and functional connectivity between brain regions.[19]

Brain-derived neurotrophic factor (BDNF) is a protein involved in neuronal survival, synaptic function and activity-dependent plasticity.[19] Exercise can influence BDNF signalling, which is one proposed pathway linking physical activity with learning, cognitive function and emotional regulation.[17][19]

However, the distinction between biological plausibility and demonstrated clinical mechanisms is important.[17] A 2025 meta-review by Vancampfort et al. of physical activity as an adjunctive treatment in mental disorders found only very preliminary evidence for changes in circulating BDNF among people with major depressive disorder, and blood BDNF measurements cannot establish that exercise has directly increased neuroplasticity in a particular brain region.[17]

Neuroplasticity provides a rationale for repeated movement practice and learning, but it does not establish that a particular exercise progression schedule will produce a specific mental health outcome.[17][19]

Stress Response and Autonomic Nervous System Regulation

The autonomic nervous system regulates involuntary functions, including heart rate, breathing and cardiovascular responses to physical and emotional demands.[3] Exercise produces a temporary increase in physiological arousal, while repeated training can lead to cardiovascular and autonomic adaptations that influence responses to physical stress.[19][3]

Heart rate variability (HRV), which reflects variation in the time intervals between heartbeats, is one measure used to investigate cardiac autonomic regulation.[3] A 2026 umbrella review of 90 reviews found that individuals with major depressive disorder generally had lower HRV than healthy comparison groups, while physical activity interventions improved several HRV measures in healthy populations.[3] These findings suggest a possible connection between exercise, autonomic function and depression, but evidence that exercise directly improves HRV in people with major depressive disorder remains insufficient.[3]

Exercise may also influence the hypothalamic–pituitary–adrenal (HPA) axis, which coordinates hormonal responses to stress, including cortisol release.[19] However, stress physiology varies with exercise intensity, duration, training status and individual health, so exercise should not be described as consistently lowering cortisol or simply switching off the body's stress response.[3]

Physiotherapists can help individuals understand that an increased heart rate or breathing rate during appropriate exercise is often a normal physiological response rather than an indication of danger.[19] This education may be particularly useful when fear of bodily sensations limits participation, although the exposure-based treatment of such fears requires additional clinical assessment.[19]

Neurotransmitters and Mood Regulation

Exercise affects several neurochemical systems involved in motivation, reward processing, attention and emotional regulation, including dopamine, serotonin, noradrenaline, glutamate and endocannabinoid signalling.[19] These systems interact with neural plasticity and stress responses rather than operating as separate pathways.[19]

Acute exercise can produce short-term changes in neurochemical activity, while repeated exercise may contribute to longer-term adaptations in neural signalling and function.[19] However, much of the detailed mechanistic evidence comes from animal or laboratory research, and it is not established that exercise improves depression or anxiety simply by increasing serotonin or dopamine levels in humans.[17][19].

Inflammation and Immune Function

Inflammatory processes have been investigated as possible contributors to the relationship between physical activity and mental health.[17][18] A 2024 systematic review identified moderate evidence that inflammation mediates the association between physical activity and depression, although the finding was based on a small number of mediation studies.[18]

The 2025 meta-review also identified preliminary evidence for exercise-related changes in inflammatory markers, including tumour necrosis factor-alpha, among people with major depressive disorder.[17] These findings suggest a possible immune-related pathway, but do not establish that reducing inflammation is the main reason exercise improves depressive symptoms.[17][18]

Sleep and Physiological Recovery

Sleep disturbance is common in mental health conditions and can affect fatigue, emotional regulation, concentration and participation in daily activities.[20] Exercise may improve perceived sleep quality and provide an additional non-pharmacological strategy for addressing sleep difficulties.[20]

A 2025 systematic review and meta-analysis of 13 randomised controlled trials involving 994 participants with depression or elevated depression risk found that aerobic exercise improved subjective sleep quality, with a standardised mean difference of −0.52 (95% confidence interval −0.66 to −0.38).[20] However, the review did not identify significant improvements in objectively measured sleep efficiency, total sleep time or sleep latency.[20]

Sleep quality, daytime fatigue and exercise tolerance are useful outcomes to consider when monitoring rehabilitation, particularly for people whose mental health symptoms interfere with daily routines.[18][20]

Psychological and Social Benefits

Physical exercise can support mental health through psychological and social pathways, including improvements in self-efficacy, emotional well-being, coping and social participation.[1][2][18] These benefits may complement the neurobiological and physiological effects of exercise and contribute to improved engagement in rehabilitation.[17][18]

Self-Efficacy, Confidence and Sense of Achievement

Self-efficacy refers to a person's belief in their ability to successfully perform a particular activity or manage a challenge.[18] Participating in structured exercise and achieving realistic goals may strengthen confidence, perceived competence and physical self-worth, particularly among individuals who have experienced prolonged inactivity or reduced functional capacity.[18]

Emotional Well-Being and Coping

Exercise has demonstrated benefits for emotional well-being.[17] Exercise may influence emotional well-being through improvements in resilience, perceived physical health and the management of pain and fatigue.[18] The systematic review by White et al. identified strong evidence for affect, resilience, pain and fatigue as mediators of the relationship between physical activity and mental health.[18]

In rehabilitation, these findings support considering psychological well-being and coping alongside physical outcomes.[18]

Physical activity can create opportunities for social interaction, shared experiences and participation in meaningful activities, particularly through group or community-based exercise.[18] Social support and social connection have been identified as potential mediators of the relationship between physical activity and mental health.[21]

Group exercise may provide opportunities for peer support and social engagement, which can be relevant for individuals experiencing social withdrawal or isolation.[21]

Implications for Graded Exercise in Mental Health Physiotherapy

These findings provide a rationale for considering physical, psychological and social outcomes when developing exercise programmes for people experiencing mental health conditions.[18] Physiotherapists can assess not only exercise tolerance and physical fitness but also confidence, sleep, fatigue, activity avoidance and participation in meaningful daily activities.[18][20][21]

The studies reviewed here largely investigate physical activity and exercise in general, rather than demonstrating that a particular graded exercise protocol produces each of these mechanisms. Graded progression should therefore be understood as a way to individualise exercise delivery, while its effectiveness and safety depend on the person's condition and rehabilitation goals.[18]

Clinical Application of Graded Approaches

The clinical application of graded approaches begins with identifying whether reduced participation is primarily related to physical deconditioning, difficulties maintaining daily activities, fear of movement or avoidance of distressing bodily sensations.[7][9][17][22] Physiotherapists should consider the person's physical health, mental health symptoms, functional limitations, preferences and goals before selecting an intervention.[17][23]

Assessment and Selection of Approach

Assessment should explore current activity levels, exercise tolerance, fatigue, pain, sleep, confidence, avoidance behaviours and the impact of symptoms on daily participation.[17][18][23] When fear limits activity, clinicians should identify the specific movement, sensation or situation being avoided and the person's expectations about what might happen.[9][12][22]

Table 2. Clinical Decision-Making for Graded Approaches in Mental Health Rehabilitation [6][7][9][12][22]

Assessment findings Clinical considerations Suggested approach
Reduced physical activity and exercise tolerance, without significant fear-related avoidance Establish baseline capacity, identify barriers and determine a manageable starting level Graded exercise
Difficulty initiating or maintaining daily activities due to low motivation, fatigue or disrupted routines Identify meaningful activities, assess daily activity patterns and agree on achievable functional goals Graded activity
Avoidance of specific movements due to anticipated pain, injury or harm Explore feared consequences, assess whether movement is medically appropriate and develop an individualised exposure hierarchy Graded exposure
Fear of increased heart rate, breathlessness or other exercise-related sensations Assess the sensations and relevant medical risks, explore catastrophic interpretations and consider planned exposure to safe bodily sensations Interoceptive exposure
Avoidance of gyms, outdoor activities or other environments associated with anxiety Identify feared situations, safety behaviours and participation goals; consider gradual exposure within the person's readiness and preferences Situational exposure

These approaches are not mutually exclusive. Selection depends on individual assessment, clinical reasoning and the person's goals. Exposure-based interventions should remain within professional competence and be coordinated with mental health professionals when appropriate

Individualised Planning and Progression

Exercise programmes should begin at an achievable level and be adjusted according to individual capacity, health status and goals.[6][23] For graded exercise, progression may involve modifying frequency, intensity, duration or exercise type rather than increasing all components simultaneously.[6][23]

For graded activity, clinicians can establish achievable functional goals and progressively support participation in meaningful activities.[7] For graded exposure, treatment planning involves identifying feared predictions, selecting relevant situations or sensations, and providing opportunities for new learning through repeated practice.[12][22]

Progression should be collaborative and responsive to clinical findings rather than automatically following fixed increases in exercise duration or intensity.[6][23]

For individuals who find structured exercise difficult to initiate or maintain, integrating manageable physical activities into daily routines may provide a more accessible starting point for increasing participation.[6]

Monitoring and Adaptation

Monitoring should include physical responses and functional outcomes alongside psychological factors such as fear, confidence, avoidance and perceived ability to participate.[7][9][23] Physiotherapists can use individual goals, activity records and relevant outcome measures to review progress and identify when treatment requires modification.[6][23]

For exposure-based interventions, progress should not be measured only by how much anxiety decreases during a session. It is also important to assess whether the person is less likely to avoid feared activities, feels more confident managing previously feared situations, and can participate in activities they previously avoided.[12][24]

Clinical Precautions and Considerations

Graded exercise, graded activity and graded exposure should be consider the following precautions:

  • Medical screening: Assess relevant medical conditions, exercise tolerance and symptoms that may require modification or further medical evaluation before initiating or progressing physical activity.[6][17]
  • Post-exertional malaise: People with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may experience delayed and prolonged worsening of symptoms following physical or cognitive exertion. Fixed-increment graded exercise therapy is not recommended for this population.[25] Physiotherapists should recognise post-exertional malaise and adapt activity management to individual energy limits rather than following predetermined exercise increases.[25]
  • Trauma-informed practice: Physical sensations, movements or exercise environments may trigger distress in people with trauma histories. Interventions should emphasise safety, informed consent, choice and collaboration, without forcing exposure or progression.[16][17]
  • Psychological readiness and professional scope: Exposure-based interventions should be planned according to the person's needs and the clinician's competencies.[16] Coordination with mental health professionals is particularly important when addressing complex anxiety, post-traumatic stress disorder or significant psychological distress.[14][16]
  • Progression should be guided by the individual's response and functional goals rather than a predetermined schedule. The aim is to support safe, meaningful participation without reinforcing avoidance or overlooking symptoms that require further assessment.[6][12]

[26]

Conclusion

Graded exercise, graded activity and graded exposure offer different but complementary approaches to addressing physical inactivity, reduced participation and fear-related avoidance in rehabilitation.[7] Their application in mental health care requires individualised assessment, appropriate progression and consideration of both physical and psychological factors.[23] Integrating these approaches within a biopsychosocial framework can support physical capacity, confidence and meaningful participation in daily life.[23]

References

  1. ↑ 1.0 1.1 1.2 Noetel M, Sanders T, Gallardo-Gómez D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847.
  2. ↑ 2.0 2.1 2.2 2.3 Singh B, Olds T, Curtis R, et al. Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. Br J Sports Med. 2023;57(18):1203-1209.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Kreppke JN, Brupbacher G, Rupf K, Hohberg V, Cody R, Gerber M, et al. Association between physical activity, heart rate variability and major depressive disorders: an umbrella review. Sports Med. 2026;56(3):703-723.
  4. ↑ Xie W, Lu D, Liu S, Li J, Li R. The optimal exercise intervention for sleep quality in adults: a systematic review and network meta-analysis. Prev Med. 2024;183:107955.
  5. ↑ Ahn J, Falk EB, Kang Y. Relationships between physical activity and loneliness: a systematic review of intervention studies. Curr Res Behav Sci. 2024;6:100141.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 López-de-Uralde-Villanueva I, Muñoz-García D, Gil-Martínez A, Pardo-Montero J, Muñoz-Plata R, Angulo-Díaz-Parreño S, et al. A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. 2016;17(1):172-188.
  8. ↑ 8.0 8.1 8.2 Zhang Q, Wu Y, Zhao Y, Meng T, Zhao Y, Qin X, et al. Effects of graded exposure on functional improvement, quality of life, and mental health in chronic musculoskeletal pain: a systematic review and meta-analysis. J Pain Res. 2026;19:631975.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 Farris SG, Derby L, Kibbey MM. Getting comfortable with physical discomfort: a scoping review of interoceptive exposure in physical and mental health conditions. Psychol Bull. 2025;151(2):131-191.
  10. ↑ The Physio Channel. Graded Exposure for Pain Explained [Internet]. YouTube; 2019 Dec 30 [cited 2026 Nov 13]. Available from: https://www.youtube.com/watch?v=HO6dyLQHQ-0
  11. ↑ 11.0 11.1 11.2 11.3 Boettcher H, Brake CA, Barlow DH. Origins and outlook of interoceptive exposure. J Behav Ther Exp Psychiatry. 2016;53:41-51. doi:10.1016/j.jbtep.2015.10.009.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 12.13 Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B. Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther. 2014;58:10-23.
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 Craske MG, Treanor M, Zbozinek TD, Vervliet B. Optimizing exposure therapy with an inhibitory retrieval approach and the OptEx Nexus. Behav Res Ther. 2022;152:104069.
  14. ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 Benito KG, Pittig A, Abramowitz JS, Arch JJ, Chavira DA, de Kleine RA, et al. Mechanisms of change in exposure therapy for anxiety and related disorders: a research agenda. Clin Psychol Sci. 2025;13(4):687-719.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 Hamlett GE, Foa EB, Brown LA. Exposure therapy and its mechanisms. Curr Top Behav Neurosci. 2023;64:273-288.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 Racz JI, Bialocerkowski A, Calteaux I, Farrell LJ, et al. Determinants of exposure therapy implementation in clinical practice for the treatment of anxiety, OCD, and PTSD: a systematic review. Clin Child Fam Psychol Rev. 2024;27:317-341.
  17. ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 17.12 17.13 17.14 17.15 17.16 17.17 Vancampfort D, Firth J, Stubbs B, Schuch F, Rosenbaum S, Hallgren M, et al. The efficacy, mechanisms and implementation of physical activity as an adjunctive treatment in mental disorders: a meta-review of outcomes, neurobiology and key determinants. World Psychiatry. 2025;24(2):227-239.
  18. ↑ 18.00 18.01 18.02 18.03 18.04 18.05 18.06 18.07 18.08 18.09 18.10 18.11 18.12 18.13 18.14 18.15 18.16 18.17 18.18 White RL, Vella S, Biddle S, Sutcliffe J, Guagliano JM, Uddin R, et al. Physical activity and mental health: a systematic review and best-evidence synthesis of mediation and moderation studies. Int J Behav Nutr Phys Act. 2024;21(1):134.
  19. ↑ 19.00 19.01 19.02 19.03 19.04 19.05 19.06 19.07 19.08 19.09 19.10 19.11 19.12 Wang X, Zhang J, Wang X, Wang S, Zhang Y, Yang Y, et al. Multiscale mechanisms of exercise-induced neuroplasticity: from molecular pathways to network dynamics and behavioral adaptation. Brain Sci. 2026;16(3):294.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Liang J, Pan X, Zhao L, Li Y. Effects of aerobic exercises at different intensities on sleep quality in individuals with depression: a systematic review and meta-analysis. Nat Sci Sleep. 2025;17:2091-2109.
  21. ↑ 21.0 21.1 21.2 Kritz M, Riddell H, Olsen D, Harden SM, Burke SM, Ntoumanis N, et al. Individual versus group-based interventions: a systematic review and meta-analysis of physical activity, functional, psychosocial and health outcomes. Nat Hum Behav. 2026;10:1109-1121.
  22. ↑ 22.0 22.1 22.2 22.3 Schemer L, Vlaeyen JWS, Glombiewski JA. From the lab to the clinic: advancing pain exposure using principles of functional analysis. Curr Opin Psychol. 2025;62:101982.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 23.7 23.8 Exercise & Sports Science Australia. Role of exercise physiologists in mental health support and recovery: 2026 Exercise and Sports Science Australia (ESSA) consensus statement. Br J Sports Med. 2026
  24. ↑ Skjerdingstad N. An inhibitory learning-based turn in exposure therapy. Nat Rev Psychol. 2024
  25. ↑ 25.0 25.1 National Institute for Health and Care Excellence. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NICE guideline NG206. London: NICE; 2021.
  26. ↑ M.E./CFS: Graded Exercise Therapy [Internet]. YouTube; 2024 Jan 7. Available from: https://www.youtube.com/watch?v=IU6wHToWFdY
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