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Post-exertional malaise
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===Characteristics === [[File:Post-exertional_Malaise_dimensions_ME_CFS.png|thumb|left|alt=Pie chart showing five dimensions. 1 Dead, heavy feeling after starting to exercise; 2 Next day soreness or fatigue after non-strenuous, everyday activities; 3 Mentally tired after the slightest effort; 4 Minimum exercise makes you physically tired; 5 Physically drained or sick after mild activity|Five dimensions of post-exertional malaise in ME/CFS. Post-exertional malaise (PEM) is not the same as [[post-exertional symptom exacerbation]].<br> Image: MEpedia. Data from: Jason (2018). [https://www.researchgate.net/publication/358281945_DePaul_Symptom_Questionnaire_-_Post-Exertional_Malaise_short_form_DSQ-PEM DePaul Symptom Questionnaire: Post-Exertional Malaise short form (DSQ-PEM)]<ref name="Cotler2018" />.]] The distinctive characteristics of post-exertional malaise were found by scientific research including patient interviews and questionnaires, then confirmed and expanded on by biomedical research, especially using [[exercise]] tests.<ref name="Cotler2018" /><ref name="Vink2015">{{Cite journal | last = Vink | first = Mark | authorlink = Mark Vink | date = 2015-09-10 | title = The Aerobic Energy Production and the Lactic Acid Excretion are both Impeded in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome|url=https://www.researchgate.net/publication/282133390_The_Aerobic_Energy_Production_and_the_Lactic_Acid_Excretion_are_both_Impeded_in_Myalgic_EncephalomyelitisChronic_Fatigue_Syndrome|journal=Journal of Neurology and Neurobiology ( ISSN 2379-7150 )|volume=1|doi=10.16966/2379-7150.112}}</ref><ref name="ICC2011primer">{{citation | last1 = Carruthers | first1 = BM | authorlink1 = Bruce Carruthers | last2 = van de Sande | first2 = MI | authorlink2 = Marjorie van de Sande | last3 = De Meirleir | first3 = KL | authorlink3 = Kenny de Meirleir | last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas | last5 = Broderick | first5 = G | authorlink5 = Gordon Broderick | last6 = Mitchell | first6 = T | authorlink6 = Terry Mitchell | last7 = Staines | first7 = D | authorlink7 = Donald Staines | last8 = Powles | first8 = ACP | authorlink8 = A C Peter Powles | last9 = Speight | first9 = N | authorlink9 = Nigel Speight | last10 = Vallings | first10 = R | authorlink10 = Rosamund Vallings | last11 = Bateman | first11 = L | authorlink11 = Lucinda Bateman | last12 = Bell | first12 = DS | authorlink12 = David Bell | last13 = Carlo-Stella | first13 = N | authorlink13 = Nicoletta Carlo-Stella | last14 = Chia | first14 = J | authorlink14 = John Chia | last15 = Darragh | first15 = A | authorlink15 = Austin Darragh | last16 = Gerken | first16 = A | authorlink16 = Anne Gerken | last17 = Jo | first17 = D | authorlink17 = Daehyun Jo | last18 = Lewis | first18 = DP | authorlink18 = Donald Lewis | last19 = Light | first19 = AR | authorlink19 = Alan Light | last20 = Light | first20 = KC | authorlink20 = Kathleen Light | last21 = Marshall-Gradisnik | first21 = S | authorlink21 = Sonya Marshall-Gradisnik | last22 = McLaren-Howard | first22 = J | authorlink22 = John McLaren-Howard | last23 = Mena | first23 = I | authorlink23 = Ismael Mena | last24 = Miwa | first24 = K | authorlink24 = Kunihisa Miwa | last25 = Murovska | first25 = M | authorlink25= Modra Murovska | last26 = Stevens | first26 = SR | authorlink26 = Staci Stevens | title = Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners | date = 2012| isbn = 978-0-9739335-3-6 | url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf}}</ref> {{See also|#DSQ-PEM|DePaul Symptom Questionnaire PEM subscale}} Too much exertion causes ME/CFS patients abnormalities in [[Cognitive dysfunction|cognitive functioning,]]<ref name="Blackwood1998">{{Cite journal | last = Blackwood | first = S. | last2 = MacHale | first2 = S. | last3 = Power | first3 = M. | last4 = Goodwin | first4 = G. | last5 = Lawrie | first5 = S. | date = Oct 1998 | title = Effects of exercise on cognitive and motor function in chronic fatigue syndrome and depression|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2170292/|journal=Journal of Neurology, Neurosurgery, and Psychiatry|volume=65|issue=4 | pages = 541β546|issn=0022-3050|pmc=2170292|pmid=9771781|via=}}</ref><ref name="Cook2017" /> [[immune activation]],<ref name="Nijs2014">{{Cite journal | last = Nijs | first = Jo | last2 = Nees | first2 = Andrea | last3 = Paul | first3 = Lorna | last4 = De Kooning | first4 = Margot | last5 = Ickmans | first5 = Kelly | last6 = Meeus | first6 = Mira | last7 = Van Oosterwijck | first7 = Jessica | authorlink = Jo Nijs | author-link2 = Andrea Nees | author-link3 = Lorna Paul | author-link4 = Margot De Kooning | author-link5 = Kelly Ickmans|via= | authorlink6 = Mira Meeus | authorlink7 = Jessica Van Oosterwijck | date = 2014 | title=Altered immune response to exercise in patients with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic literature review | url = https://www.ncbi.nlm.nih.gov/pubmed/24974723|journal=Exercise Immunology Review|volume=20 | pages = 94β116|issn=1077-5552|pmid=24974723|issue=|quote=}}</ref> [[gene expression]]<ref name="Light2009">{{Cite journal | last = Light | first=Alan R. | author-link = Alan Light | last2 = White | first2 = Andrea T. | authorlink2 = Andrea White | last3 = Hughen | first3 = Ronald W. | last4 = Light | first4 = Kathleen C. | authorlink4 = Kathleen Light | date = Oct 2009 | title = Moderate Exercise Increases Expression for Sensory, Adrenergic, and Immune Genes in Chronic Fatigue Syndrome Patients But Not in Normal Subjects|url=http://dx.doi.org/10.1016/j.jpain.2009.06.003|journal=The Journal of Pain|volume=10|issue=10|pages=1099β1112|doi=10.1016/j.jpain.2009.06.003|issn=1526-5900}}</ref><ref name="Light2011">{{Cite journal | last = Light | first=A.R. | authorlink = Alan Light | last2 = Bateman | first2 = L. | authorlink2 = Lucinda Bateman | last3 = Jo | first3 = D. | last4 = Hughen | first4 = R.W. | last5 = VanHaitsma | first5 = T.A. |last6 = White | first6 = A.T. | authorlink6 = Andrea White | last7 = Light | first7 = K.C. | authorlink7 = Kathleen Light | date = 2011-07-13 | title = Gene expression alterations at baseline and following moderate exercise in patients with Chronic Fatigue Syndrome and Fibromyalgia Syndrome|url=http://dx.doi.org/10.1111/j.1365-2796.2011.02405.x|journal=Journal of Internal Medicine|volume=271|issue=1 | pages = 64β81|doi=10.1111/j.1365-2796.2011.02405.x|issn=0954-6820}}</ref><ref name="Meyer2013">{{Cite journal | last = Meyer | first=Jacob D. | last2 = Light | first2 = Alan R. | authorlink2 = Alan Light | last3 = Shukla | first3 = Sanjay K. | last4 = Clevidence | first4 = Derek | last5 = Yale | first5 = Steven | last6 = Stegner | first6 = Aaron J. | last7 = Cook | first7 = Dane B. | authorlink7 = Dane Cook | date = Oct 2013 | title = Post-exertion malaise in chronic fatigue syndrome: symptoms and gene expression|url=http://dx.doi.org/10.1080/21641846.2013.838444|journal = Fatigue: Biomedicine, Health & Behavior |volume=1|issue=4|pages=190β209|doi=10.1080/21641846.2013.838444|issn=2164-1846}}</ref><ref name="White2011">{{Cite journal | last = White | first = A. T. | author-link = Andrea White | last2 = Light | first2 = A.R. | authorlink2 = Alan Light | last3 = Hughen | first3 = R.W. | last4 = VanHaitsma | first4 = T.A. | last5 = Light | first5 = K.C. | authorlink5 = Kathleen Light | date = 2011-12-30 | title = Differences in Metabolite-Detecting, Adrenergic, and Immune Gene Expression After Moderate Exercise in Patients With Chronic Fatigue Syndrome, Patients With Multiple Sclerosis, and Healthy Controls|url=http://dx.doi.org/10.1097/psy.0b013e31824152ed|journal=Psychosomatic Medicine|volume=74|issue=1 | pages = 46β54|doi=10.1097/psy.0b013e31824152ed|issn=0033-3174}}</ref> and endogenous pain inhibition<ref name="Whiteside2004">{{Cite journal | last = Whiteside | first = Alan | last2 = Hansen | first2 = Stig | last3 = Chaudhuri | first3 = Abhijit | date = Jun 2004 | title = Exercise lowers pain threshold in chronic fatigue syndrome|url=http://dx.doi.org/10.1016/j.pain.2004.02.029|journal=Pain|volume=109|issue=3 | pages = 497β499|doi=10.1016/j.pain.2004.02.029|issn=0304-3959}}</ref><ref name="Meeus2010">{{Cite journal | last = Meeus | first = M | last2 = Roussel | first2 = NA | last3 = Truijen | first3 = S | date = 2010 | title=Reduced pressure pain thresholds in response to exercise in chronic fatigue syndrome but not in chronic low back pain: An experimental study|url=http://dx.doi.org/10.2340/16501977-0595|journal=Journal of Rehabilitation Medicine|volume=42|issue=9 | pages = 884β890|doi=10.2340/16501977-0595|issn=1650-1977}}</ref><ref name="VanOosterwijck2010">{{Cite journal | last = Van Oosterwijck | first = J. | author-link = Jessica Van Oosterwijck | last2 = Nijs | first2 = J. | authorlink2 = Jo Nijs | last3 = Meeus | first3 = M. | authorlink3 = Mira Meeua | last4 = Lefever | first4 = I. | last5 = Huybrechts | first5 = L. | last6 = Lambrecht | first6 = L. | last7 = Paul | first7 = L. | authorlink7 = Lorna Paul | date = 2010-03-03 | title = Pain inhibition and postexertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome: An experimental study|url=http://dx.doi.org/10.1111/j.1365-2796.2010.02228.x|journal=Journal of Internal Medicine|volume=268|issue=3|pages=265β278|doi=10.1111/j.1365-2796.2010.02228.x|issn=0954-6820|quote=}}</ref> in ME/CFS patients that were not seen before exertion or in healthy controls. {{See also|List of abnormal findings in chronic fatigue syndrome and myalgic encephalomyelitis}} Most importantly PEM can be demonstrated by a [[Two-day cardiopulmonary exercise test|2-day cardiopulmonary exercise test]] (CPET) procedure.<ref name="Stevens2018" /><ref name="Unrest-film" /> On the second day [[Two-day cardiopulmonary exercise test|CPET]], ME/CFS patients display a significant drop in VO2 max and maximal workload, that is not seen in healthy controls or other diseases.<ref name="Snell2013">{{Cite journal | last = Snell | first = Christopher R. | authorlink1 = Christopher Snell | last2 = Stevens | first2 = Staci R | authorlink2 = Staci Stevens | last3 = Davenport | first3 = Todd E. | authorlink3 = Todd Davenport | last4 = VanNess | first4 = J. Mark | authorlink4 = Mark VanNess | date = 2013-06-27 | title = Discriminative Validity of Metabolic and Workload Measurements for Identifying People With Chronic Fatigue Syndrome|url=https://academic.oup.com/ptj/article/93/11/1484/2735315|journal=Physical Therapy|volume=93|issue=11|pages=1484β1492|doi=10.2522/ptj.20110368|issn=0031-9023}}</ref><ref name="Vermeulen2010">{{Cite journal | last = Vermeulen | first = Ruud CW | last2 = Kurk | first2 = Ruud M | last3 = Visser | first3 = Frans C | last4 = Sluiter | first4 = Wim | last5 = Scholte | first5 = Hans R | date = 2010 | title=Patients with chronic fatigue syndrome performed worse than controls in a controlled repeated exercise study despite a normal oxidative phosphorylation capacity|url=http://dx.doi.org/10.1186/1479-5876-8-93|journal=Journal of Translational Medicine|volume=8|issue=1 | pages = 93|doi=10.1186/1479-5876-8-93|issn=1479-5876}}</ref><ref name="Keller2014" /><ref name="VanNess2007">{{Cite journal | last1 = VanNess | first1 = J Mark | authorlink1 = Mark VanNess | last2 = Snell | first2 = Christopher R | authorlink2 = Christopher Snell | last3 = Stevens | first3 = Staci R | authorlink3 = Staci Stevens | title = Diminished Cardiopulmonary Capacity During Post-Exertional Malaise| journal = Journal of Chronic Fatigue Syndrome | volume = 14 | issue = 2 | pages = 77-85 | date = 2007 | pmid = | url = https://www.researchgate.net/publication/249887130_Diminished_Cardiopulmonary_Capacity_During_Post-Exertional_Malaise | doi = 10.1300/J092v14n02_07}}</ref><ref name="Hodges2018" /> These objective measures track strongly with the presence, severity and duration of PEM.<ref name="IOM2015">{{Cite book |url=http://www.ncbi.nlm.nih.gov/books/NBK274235/ | title = Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness | last = Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome | last2 = Board on the Health of Select Populations | last3 = Institute of Medicine | date = 2015 | publisher=National Academies Press (US)|isbn=9780309316897|series=The National Academies Collection: Reports funded by National Institutes of Health|location=Washington (DC)|pmid=25695122}}</ref><ref name="ICC" /> <ref name="Loy2013">{{Cite journal | last = Loy | first = Bryan D. | last2 = O'Connor | first2 = Patrick J. | last3 = Dishman | first3 = Rodney K. | date = Oct 2013 | title = The effect of a single bout of exercise on energy and fatigue states: a systematic review and meta-analysis|url=https://www.tandfonline.com/doi/abs/10.1080/21641846.2013.843266?journalCode=rftg20|journal = Fatigue: Biomedicine, Health & Behavior |language=en|volume=1|issue=4|pages=223β242|doi=10.1080/21641846.2013.843266|issn=2164-1846}}</ref> [[Brian Vastag]] won a groundbreaking long term disability (LTD) claim using CPET to prove his PEM was a severe disabling symptom.<ref name="Vastag-Prudential">{{Citation|url=https://cases.justia.com/federal/district-courts/new-jersey/njdce/2:2015cv06197/323449/44/0.pdf?ts=1527932072 | last = US District Court District of New Jersey | title = Brian Vastag v. Prudential Insurance Company of America, Civ. No. 15-6197 (KSH) (CLW) (D.N.J. May. 31, 2018)}}</ref><ref name="Vastag-wins">{{Cite web|url=https://www.meaction.net/2018/06/04/victory-for-me-disability-claim-court-upholds-plaintiffs-lawsuit-after-being-denied-disability/ | title = Victory for ME Disability Claim - U.S. Court Upholds Plaintiff's Lawsuit After Being Denied Disability | last = Tillman | first=Adriane | author-link = | date = 2018-06-04 | website = #MEAction|language=en-US|archive-url=|archive-date=|url-status=|access-date=2019-02-02}}</ref> A 2015 review of the literature by the [[National Academy of Medicine]] concluded there to be "sufficient evidence that PEM is a primary feature that helps distinguish ME/CFS from other conditions."<ref name="IOM2015" /> Disagreement exists however on the precise nature of PEM and how it should be defined,<ref name="Jason2015">{{Cite journal | last= Jason | first = Leonard A. | author-link = Leonard Jason | last2 = Evans | first2 = Meredyth | last3 = So | first3 = Suzanna | last4 = Scott | first4 = Jilian | last5 = Brown | first5 = Abigail | date = 2015 | title=Problems in Defining Post-Exertional Malaise|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295644/|journal=Journal of prevention & intervention in the community|volume=43|issue=1|pages=20β31|doi=10.1080/10852352.2014.973239|issn=1085-2352|pmc=4295644|pmid=25584525}}</ref> with some diagnostic criteria emphasizing [[Paresis|muscle weakness]] and others a more a general form of [[fatigue]] and exhaustion.<ref name="McManimen2016" /> [[File:2010 VanNess Post exertional worsening of symptoms chart.png|right|frame|Post-exertional worsening of symptoms<ref name="VanNess2010" />]] The [[Centers for Disease Control and Prevention]] (CDC) outline different types of exertion that may trigger PEM and how it impacts patients noting some may be housebound or completely bedbound during a crash. "People with ME/CFS may not be able to predict what will cause a crash or how long it will last."<ref name="CDC-symptoms">{{Cite web|url=https://www.cdc.gov/me-cfs/symptoms-diagnosis/symptoms.html | title = Symptoms {{!}} Myalgic Encephalomyelitis/Chronic Fatigue Syndrome | date = 2018-05-18 | website = [[Centers for Disease Control and Prevention]]|language=en-us|access-date=2018-11-21}}</ref>
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