Post-exertional malaise

Post-exertional malaise (PEM), sometimes referred to as post-exertional symptom exacerbation (PESE),[1] is a worsening of chronic fatigue syndrome or long COVID symptoms that occurs after exertion.[1] PEM is often severe enough to be disabling, and is triggered by ordinary activities that healthy people tolerate. Typically, it begins 12–48 hours after the activity that triggers it, and lasts for days, but this is highly variable.[2][3][4] Management of PEM is symptomatic, and patients are recommended to pace their activities to avoid triggering PEM.

Post-exertional malaise
Other namesPost-exertional symptom exacerbation (PESE)
Postexertional malaise
Diagram with examples of cognitive, physical, and emotional activities that may trigger PEM
Chart of physical, cognitive, and emotional activities that may trigger PEM
SymptomsWorsening of symptoms after ordinary activity
CausesChronic fatigue syndrome
Long COVID
TreatmentSymptomatic

Description
A line graph of symptom levels of several people, showing delayed increases after activity
Severe symptoms triggered by a 2-day CPET in people with ME/CFS

Post-exertional malaise involves an exacerbation of symptoms, often severely enough to impact a person's functioning. While fatigue is often prominent, it is "more than fatigue following a stressor."[4] Other symptoms that may occur during PEM include cognitive impairment, flu-like symptoms, pain, weakness, and trouble sleeping.[4][2] Despite being typically cast as a worsening of existing symptoms, patients may experience some symptoms exclusively during PEM.[4] Patients often describe PEM as "crash," "relapse," or "setback."[4]

PEM is triggered by "minimal"[3] physical or mental activities that were previously tolerated, and that healthy people tolerate, like attending a social event, grocery shopping, or even taking a shower.[2] Emotional distress, injury, sleep deprivation, infections, and spending too long standing or sitting up are other as potential triggers.[4] The resulting symptoms are disproportionate to the triggering activity and are often debilitating, potentially rendering someone housebound or bedbound until they recover.[5][4][6][2]

The course of a crash is highly variable. Symptoms typically begin 12–48 hours after the triggering activity,[3] but may be immediate, or delayed up to 7 days.[4] PEM lasts "usually a day or longer,"[5] but can span hours, days, weeks, or months.[4] The level of activity that triggers PEM, as well as the symptoms, vary from person to person, and within individuals over time.[4] Due to this variability, affected people may be unable to predict what will trigger it.[2] This variable, relapsing-remitting pattern can cause one's abilities to fluctuate from one day to the next.[1]

Diagnosis

PEM is a common symptom of both ME/CFS and long COVID.[7][8]

Its presence can be difficult to assess because patients and doctors may be unfamiliar with it.[1][7] Hence, the WHO recommends that clinicians explicitly ask long COVID patients whether symptoms worsen with activity.[1]

The 2-day Cardiopulmonary Exercise Test (CPET) may aid in documenting PEM, showing apparent abnormalities in the body's response to exercise.[9] Still, more research on developing a diagnostic test is needed.

Epidemiology

Depending on the definition of ME/CFS used, PEM is present in 60 to 100% of ME/CFS patients.[4] PEM is considered a cardinal symptom by some diagnostic criteria: the International Consensus Criteria,[2][5] the National Academy of Medicine criteria,[10][11] and NICE's definition of CFS[6] all require it. The Canadian Consensus Criteria require "post exertional malaise and/or [post exertional] fatigue" instead.[12][13][14][10][15] On the other hand, the older Oxford Criteria lack any mention of PEM,[16] and the Fukuda Criteria consider it optional.

Studies have found that a majority of people with long COVID experience post-exertional malaise as well.[7]

Management
Main article: Chronic fatigue syndrome treatment

There is no treatment or cure for PEM. Pacing, a management strategy in which someone plans their activities to stay within their limits, may help avoid triggering PEM.[17]

Pacing has been shown to reduce the number of PESE episodes in a cohort of people with long COVID, [18] however Physical therapy for people with long COVID must be modified to avoid triggering PEM in susceptible patients.[19]

References
  1. Clinical management of COVID-19 Living Guideline. World Health Organization. 13 January 2023. pp. 113–4. Retrieved 14 January 2023.
  2. "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Symptoms". Centers for Disease Control and Prevention. U.S. Department of Health & Human Services. 14 July 2017. Retrieved 23 September 2017.
  3. "Terms: Post-exertional malaise". Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management - Recommendations. NICE (Report). 29 October 2021. NICE guideline NG206.
  4. "Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness" (PDF). National Academy of Medicine. 2015. pp. 78–86. Retrieved 12 May 2022.
  5. Carruthers, B. M.; van de Sande, M. I.; De Meirleir, K. L.; Klimas, N. G.; Broderick, G.; Mitchell, T.; Staines, D.; Powles, A. C. P.; Speight, N.; Vallings, R.; Bateman, L.; Baumgarten-Austrheim, B.; Bell, D. S.; Carlo-Stella, N.; Chia, J.; Darragh, A.; Jo, D.; Lewis, D.; Light, A. R.; Marshall-Gradisbik, S.; Mena, I.; Mikovits, J. A.; Miwa, K.; Murovska, M.; Pall, M. L.; Stevens, S. (October 2011). "Myalgic encephalomyelitis: International Consensus Criteria". Journal of Internal Medicine. 270 (4): 327–338. doi:10.1111/j.1365-2796.2011.02428.x. PMC 3427890. PMID 21777306.
  6. "1.2 Suspecting ME/CFS". Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management – Recommendations. NICE (Report). 29 October 2021. NICE guideline NG206.
  7. Davis, Hannah E.; McCorkell, Lisa; Vogel, Julia Moore; Topol, Eric J. (13 January 2023). "Long COVID: major findings, mechanisms and recommendations". Nature Reviews Microbiology: 1–14. doi:10.1038/s41579-022-00846-2. ISSN 1740-1534. PMC 9839201. PMID 36639608. Retrieved 20 January 2023.
  8. "Long COVID or Post-COVID Conditions". Centers for Disease Control and Prevention. 1 September 2022.
  9. Eun-Jin, Lim; Eun-Bum, Kang; Eun-Su, Jang; Chang-Gue, Son (2020). "The Prospects of the Two-Day Cardiopulmonary Exercise Test (CPET) in ME/CFS Patients: A Meta-Analysis". Journal of Clinical Medicine. J Clin Med. 9 (12): 4040. doi:10.3390/jcm9124040. PMC 7765094. PMID 33327624.
  10. "IOM 2015 Diagnostic Criteria | Diagnosis | Healthcare Providers | Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) | CDC". www.cdc.gov. 2018-11-08. Retrieved 2019-03-08.
  11. "Symptoms of ME/CFS | Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)". CDC. 2021-01-27.
  12. Myhill, Sarah; Booth, Norman E; McLaren-Howard, John (2009). "Chronic fatigue syndrome and mitochondrial dysfunction" (PDF). Int J Clin Exp Med. 2 (1): 1–16. PMC 2680051. PMID 19436827.
  13. Carruthers, Bruce M; van de Sande, Marjorie I. (2005). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Clinical Case Definition and Guidelines for Medical Practitioners" (PDF). sacfs.asn.au. p. 8. There is an inappropriate loss of physical and mental stamina, rapid muscular and cognitive fatigability, post exertional malaise and/or fatigue and/or pain and a tendency for other associated symptoms within the patient's cluster of symptoms to worsen.
  14. "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Key Facts" (PDF). nap.edu. 2015. p. 2.
  15. Wright Clayton, Ellen; Alegria, Margarita; Bateman, Lucinda; Chu, Lily; Cleeland, Charles; Davis, Ronald; Diamond, Betty; Ganlats, Theodore; Keller, Betsy (2015). "Beyond Myalgic Encephalomyelits/Chronic Fatigue Syndrome: Redefining an Illness (Report Guide for Clinicians)" (PDF). nationalacademies.org. Nancy Klimas, A. Martin Lerner, Cynthia Mulrow, Benjamin Natelson, Peter Rowe, Michael Shelanski. National Academy of Medicine (Institutes of Medicine). p. 7.
  16. Sharpe, Michael (February 1991). "A report--chronic fatigue syndrome: guidelines for research". Journal of the Royal Society of Medicine. 84 (2): 118–121. doi:10.1177/014107689108400224. PMC 1293107. PMID 1999813.
  17. "1.11 Managing ME/CFS". Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management – Recommendations. NICE (Report). 29 October 2021. NICE guideline NG206.
  18. Parker, Megan; Sawant, Hannah Brady; Flannery, Thuvia; Tarrant, Rachel; Shardha, Jenna; Bannister, Rebecca; Ross, Denise; Halpin, Stephen; Greenwood, Darren C.; Sivan, Manoj (2022-12-02). "Effect of using a structured pacing protocol on post‐exertional symptom exacerbation and health status in a longitudinal cohort with the post‐COVID‐19 syndrome". Journal of Medical Virology. 95 (1). doi:10.1002/jmv.28373. ISSN 0146-6615. PMC 9878088. PMID 36461167.
  19. Clinical management of COVID-19 Living Guideline. World Health Organization. 13 January 2023. p. 109. Retrieved 14 January 2023.
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