From the Guidelines
Post-exertional malaise is best managed through pacing, as exercise, cognitive behavioral therapy, and graded exercise therapy are contraindicated. According to the most recent study published in Nature Reviews Microbiology in 2023 1, pacing is the recommended treatment for postexertional malaise, based on ME/CFS literature. This approach involves balancing activity with rest periods to avoid exacerbating symptoms.
Key Considerations
- Pacing should be individualized, taking into account the patient's specific needs and limitations.
- Techniques such as the energy envelope theory or heart rate monitoring can be used to help patients stay within their physical limits.
- It is essential to avoid pushing through symptoms, as this can worsen post-exertional malaise.
Additional Support
While pacing is the primary recommendation, other treatments may be considered to help manage related symptoms. For example, low-dose naltrexone, coenzyme Q10, and d-ribose may be useful in reducing fatigue and pain, although these are based on ME/CFS literature and not specifically studied in the context of post-exertional malaise in long COVID 1.
Importance of Monitoring
Patients should track their symptoms, energy levels, and activities in a daily journal to identify triggers and patterns, allowing for more effective management of post-exertional malaise. This approach, combined with pacing, can help improve quality of life and reduce morbidity associated with post-exertional malaise.
From the Research
Definition and Characteristics of Post-Exertional Malaise
- Post-exertional malaise (PEM) is a cardinal symptom of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and is characterized by an exacerbation of symptoms that leads to a reduction in functionality 2.
- PEM is reported to occur in many patients with ME/CFS, and its assessment is crucial for the diagnosis and treatment of the condition 3.
- The symptom can be composed of two empirically different experiences: generalized fatigue and muscle-specific fatigue 4.
Diagnosis and Treatment of Post-Exertional Malaise
- Recognition of PEM is important for the diagnosis and treatment of ME/CFS, and its assessment can be improved by understanding how the symptom is reported by patients 3.
- Energy management or pacing is a prominent coping strategy for people with ME/CFS, which involves regulating activity to avoid PEM 5.
- Pacing has been shown to have benefits in reducing symptoms of ME/CFS, but the evidence is heterogeneous and more research is needed to inform treatment practices 5.
Relationship with Other Conditions
- Post-exertional malaise is also relevant to the rehabilitation of people with post-COVID-19 condition (PCC), and interventions effective for ME/CFS may be applicable to PCC 6.
- Effective interventions for fatigue and exercise intolerance in other health conditions, such as cancer and chronic obstructive pulmonary disease, may also be relevant to ME/CFS and PCC 6.
- However, more research is needed to specifically address post-exertional malaise and orthostatic intolerance in the context of ME/CFS and PCC 6.