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== Criticism == ===Focus on symptoms? === Some have argued that close monitoring of symptoms might aggravate distress and disability.<ref>{{Cite journal | last = Heins | first = Marianne | last2 = Knoop | first2 = Hans | last3 = Nijs | first3 = Jo | last4 = Feskens | first4 = Remco | last5 = Meeus | first5 = Mira | last6 = Moorkens | first6 = Greta | last7 = Bleijenberg | first7 = Gijs| date = Jun 2013| title = Influence of symptom expectancies on stair-climbing performance in chronic fatigue syndrome: effect of study context|url=https://www.ncbi.nlm.nih.gov/pubmed/22865100|journal=International Journal of Behavioral Medicine|volume=20|issue=2|pages=213–218|doi=10.1007/s12529-012-9253-2|issn=1532-7558|pmid=22865100}}</ref><ref>Dittner, A., & Chalder, T. (2003). Measuring symptoms and fatigue severity. In L.A. Jason., P.A. Fennell., & R.R. Taylor (Eds.), Handbook of chronic fatigue syndrome (pp. 363-383). New Jersey: John Wiley & Sons.</ref> According to Goudsmit & Howes, however “it is important to differentiate between responding to symptoms as one becomes aware of them, an inherent part of pacing, and constant monitoring, which is unnecessary and should be discouraged.”<ref name=":0" /> ===Trapped in the envelope?=== Others have argued that pacing might hamper recovery as it lets symptoms of pain and fatigue determine the amount of activity patients do. According to [[Peter White]]: the theoretical risk of pacing is that the patient remains trapped by their symptoms in the envelope of ill health".<ref>{{Cite journal | last = White | first = P. D. | date = Aug 2002| title = Chronic unexplained fatigue|url=https://www.ncbi.nlm.nih.gov/pubmed/12185213|journal=Postgraduate Medical Journal|volume=78|issue=922 | pages = 445–446|issn=0032-5473|pmc=1742445|pmid=12185213}}</ref> Pacing however does not limit the activity of patients, as long as they feel they are up to it. Goudsmit wrote: “my concept of pacing means responding to your symptoms so if you feel OK, there's no reason to stop. If you want to increase your activity levels, you are free to do so as long as you don't over-exert yourself in the process.”<ref name=":1" /> === Reliance on subjective symptoms instead of objective limits === Researchers from the [[Workwell Foundation]] have argued that self-managed pacing puts too much emphasis on the subjective experience of symptoms and that objective limits to avoid relapse are preferable. In 2010 [[Todd Davenport|Davenport]] et al. wrote: <blockquote>“To date, recommendations for pacing self-management in people with CFS/ME have been made on the basis of symptom acuity and irritability. Although these criteria seem to be intuitive, they may fail to account for the rapid changes in function that are characteristic of CFS/ ME. An impaired perception of effort in people with CFS/ME may interfere with the optimal maintenance of symptom-free activity levels if pacing self-management criteria that are based solely on symptomatology are used.”<ref>{{Cite journal | last = Davenport | first = Todd E. | last2 = Stevens | first2 = Staci R. | last3 = VanNess | first3 = Mark J. | last4 = Snell | first4 = Christopher R. | last5 = Little | first5 = Tamara | date = Apr 2010| title = Conceptual model for physical therapist management of chronic fatigue syndrome/myalgic encephalomyelitis|url=https://www.ncbi.nlm.nih.gov/pubmed/20185614|journal=Physical Therapy|volume=90|issue=4 | pages = 602–614|doi=10.2522/ptj.20090047|issn=1538-6724|pmid=20185614}}</ref> </blockquote>As an alternative the authors propose to [[Activity management based on 2-day cardiopulmonary exercise testing results|use a cardiopulmonary exercise test (CPET) to gather information about the patient’s physiology]]. The [[anaerobic threshold]] (AT) in particular can be seen as the boundary where exercise becomes harmful for ME/CFS patients. Davenport et al. suggest that a 10% margin below the estimated heart rate at the AT should be used as an exercise limit. Patients can set a heart rate monitor to make an alarm noise, each time the heart rate exceeds this limit. This might provide more reliable feedback to avoid relapses than the mere perception of muscle weakness originally used in pacing. A case study by Stevens and Davenport (2010) describes the use of pacing in a patient with CFS using a heart rate set to below the patient's anaerobic threshold; this resulted in significant improvements and reduced periods of over-exertion.<ref name="HRpacing2010" /> ===Too much activity? === Instead of advising too little activity, some have argued that pacing actually instructs patients to do too much. ME advocate [[Gabby Klein]], for example wrote: “My treating physician - Dr. [[Derek Enlander|Enlander]] - always told me to do 50% of what I think I can do. It was the best advice I got. There is much more potential harm from activity/exercise than from rest.”<ref>{{Cite news | url=https://twitter.com/GabbyKlein1/status/1026561377828306947| title = Gabby Klein on Twitter|work=Twitter|access-date=2018-08-20|language=en}}</ref> ME blogger Sally Burch argued that ME/CFS patients will usually do too much activity, so that the best advice a physician can give, is preemptive rest.<ref>{{Cite news | url=https://twitter.com/KeelaToo/status/1026727305585074176| title = Sally Burch on Twitter|work=Twitter|access-date=2018-08-20|language=en}}</ref> According to Goudsmit and Jason however, advising patients to do less than they could without exacerbating symptoms, might impede them from engaging in meaningful activities such as contact with friends and family. As such, preemptive rest might increase distress and disability.<ref name=":13" />
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