Treating/Managing Post-Exertional Malaise in Chronic Fatigue Syndrome

Post-Exertional Malaise (Part 3 of 3)

Post-exertional malaise (PEM) is a symptom of chronic fatigue syndrome (ME/CFS) that causes a spike in symptoms and a massive energy crash after what, to other people, would be minor exertion.

Even though PEM is one of the most debilitating symptoms of ME/CFS, we don't yet have any drugs for treating it. However, you may be able to treat and manage it in a couple of different ways.

Nutritional Supplements

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We don't have much research specifically on supplements for PEM, but some doctors make recommendations based on known functions of supplements, abnormalities associated with PEM, and anecdotal information from patients.

Supplements that are sometimes suggested include:

Supplements aren't guaranteed to work, though. Also, you need to be aware of the side effects and possible negative interactions they come with. It's important to talk to your doctor and pharmacist about all the supplements you take.

It can be a bad idea to start taking a bunch of supplements at once. For more information on that, see:

Pacing & Lifestyle Changes

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Managing PEM often requires changes to the way you do things. Some people call this "living within the energy envelope." The most popular explanation in the patient community is an essay called The Spoon Theory, by Christine Miserandino.

Essentially, you have to gear down your activity level to the amount that your body can handle. That may mean making a lot of sacrifices and paring your life down to the bare essentials. This often includes incredibly difficult decisions, but it can make a huge difference in your quality of life.

A 2012 consensus document on pacing for ME/CFS (Goudsmit) showed that pacing was consistently rated by patients as one of the most helpful therapeutic options.

For help making these changes and learning pacing techniques to make the most of your productive time, see:

Stress Management

ME/CFS is believed to be worsened by stress, which is something you've likely learned for yourself. It's understandable, then, that stress management may help you manage key symptoms, including PEM.

It's important to understand that ties to stress do NOT mean that ME/CFS is a psychological illness. Stress has myriad physiological causes and effects. One that's received a lot of attention from ME/CFS researchers is the stress hormone cortisol.

In a 2014 study on stress and PEM (Hall), researchers concluded that stress management had an indirect effect on PEM. Essentially, those with better stress management had better morning cortisol levels, and those cortisol levels were linked to less severe PEM.

Exercise: The Controversial Approach

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Now we come to perhaps the most controversial aspect of managing ME/CFS. You're probably asking, "How can exercise help when it's the cause of the problem in the first place?"

Most experts agree that people with ME/CFS need to get some exercise. After all, muscle atrophy and inactivity will only serve to make you less able to handle activity, while they increase other symptoms as well as your risk of other diseases.

However, you can't treat therapeutic exercise like other people. You must know your limits and stick to them strictly.

Some people turn to physical therapy, but with mixed results. It's important that your therapist is familiar with the restrictions inherent to the disease so they don't push you too far and make you worse.

A segment of the medical community advocates a treatment called Graduated Exercise Therapy (GET) as a first-line treatment for ME/CFS. They point to research suggesting that it's beneficial. On the other side of this considerable controversy, though, is research suggesting that GET is actually harmful to people with ME/CFS.

How is it that they can have such a fundamental disagreement? In comes from a difference of opinion as to the very nature of the illness. You can learn more about that here:

General Treatments

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It's possible that ME/CFS treatments not directly aimed at PEM may help with this symptom by lessening the overall severity of your disease. You have a lot of treatment options to explore, with the help of your doctor.

Again, be sure to discuss all of your treatments with your doctor to ensure that your choices are safe and likely to be effective. You'll likely need to find a unique combination of treatments and management strategies tailored to your specific symptoms and situation.

See Parts 1 & 2 of this series:


Gladwell PW, et al. Disability and rehabilitation. 2014;36(5):387-94. Use of an online survey to explore positive and negative outcomes of rehabilitation for people with CFS/ME.

Goudsmit Em, et al. Disability and rehabilitation. 2012;34(13):1140-7. Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document.

Hall Dl, et al. Psychoneuroendocrinology. 2014 Nov;49:26-31. Stress management skills, cortisol awakening response, and post-exertional malaise in chronic fatigue syndrome.

Klasnja A, et al. Journal of sports medicine and physical fitness. 2014 Apr;54(2):210-5. Influence of graded exercise therapy on anxiety levels and health-related quality of life in chronic fatigue syndrome.

Twisk FM, Maes M. Neuro endocrinology letters. 2009;30(3):284-99. A review on cognitive behavioral therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS.

White PD, et al. Psychological medicine. 2013 Oct;43(10):2227-35. Recovery from chronic fatigue syndrome after treatments given in the PACE trial.

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