Post Exertional Neuro-Immune Exhaustion (PENE), the cardinal feature of Myalgic Encephalomyelitis (ME), has long been misunderstood derided & ignored.
Believing ME can be cured by attitude & effort is stigmatizing, harmful for individuals & for the community of people affected by ME.
 |
| Image by JS |
Myalgic Encephalomyelitis (ME) is a severely debilitating disease characterised by immune, neurological and cardiac dysfunction with severe worsening of symptoms following ANY exertion. Myalgic Encephalomyelitis is the name recommended for those meeting the International Consensus Criteria (ICC).
Post Exertional Neuroimmune Exhaustion - PENE, is the cardinal feature of ME according to the International Consensus Criteria (ICC) on ME. PENE refers to the atypical post exertion response in ME and is the term recommended for those meeting the ICC.
"Cardinal symptom: a pathological low threshold of fatigability that is characterized by an inability to produce sufficient energy on demand. There are measurable, objective, adverse responses to normal exertion, resulting in exhaustion, extreme weakness, exacerbation of symptoms, and a prolonged recovery period." Pg 1 International Consensus Primer
"Post- Exertional Neuroimmune Exhaustion (PENE pen׳-e) - Normal fatigue is proportional to the intensity and duration of activity, followed by a quick restoration of energy. PENE is characterized by a pathological low threshold of physical and mental fatigability, exhaustion, pain, and an abnormal exacerbation of symptoms in response to exertion. It is followed by a prolonged recovery period. Fatigue and pain are part of the body’s global protection response and are indispensable bioalarms that alert patients to modify their activities in order to prevent further damage.
The underlying pathophysiology of PENE involves a profound dysfunction of the regulatory control network within and between the nervous systems. This interacts with the immune and endocrine systems affecting virtually all body systems, cellular metabolism and ion transport. The dysfunctional activity/rest control system and loss of homeostasis result in impaired aerobic energy production and an inability to produce sufficient energy on demand. A test-retest cardiopulmonary exercise study revealed a drop of 22% in peak VO2 and 27% in VO2 at AT on the second day evaluation. Both submaximal and self-paced exercise resulted in PENE.These impairments and the loss of invigorating effects distinguish ME from depression." Pg 2 International Consensus Primer
- Post Exertional Neuroimmune Exhaustion - PENE is a distinct measurable feature related to exhaustion and the nervous and immune systems.
- ME patients who exceed the safe activity threshold suffer post-exertional neuroimmune exhaustion (PENE) which can lead to serious deterioration.
- Onset of PENE may occur immediately or may be delayed by hours or days with a prolonged recovery period.
- The severity of PENE, the speed of onset of PENE whether immediate or delayed, and the recovery rate may fluctuate in an individual though an activity baseline needs to be established and not exceeded.
- Post Exertional Neuroimmune Exhaustion - PENE is particular to ME, however we recognise and appreciate that the term Post Exertional Malaise - PEM can be used when referring to this cardinal feature in ME, though PEM is common in other illnesses too and not the same as PENE.
- There is a long list of atypical symptoms that occur when a person with ME suffers from Post Exertional Neuro-Immune Exhaustion - PENE; marked debilitating physical illness and weakness, cognitive dysfunction, and symptom flare-up can follow ANY physical or cognitive exertion requiring energy, no matter how small or insignificant the exertion.
- PENE can lead to cognitive and muscle dysfunction to the point of paralysis and loss of speech. PENE can also exacerbate the immune dysfunction leading to reactivation of viral and bacterial infections.
- PENE is a required feature for an ME diagnosis.
- PENE is disproportionate to the activity or exertion.
- PENE relates to the physical inability to produce sufficient energy on demand. Because PENE limits the ability to be mentally and physically active, it often leads to activity/work disability. Once someone suspects an ME diagnosis because of the presence of PENE, it is advisable to stop activity and work immediately. Do not push through PENE or your chance of recovery or staying in a more moderate severity category will be limited; staying within the limited energy production window as early as possible following illness onset leads to a best long-term outcome.
- Essentially what PENE means is that any exertion, physical, cognitive or even emotional stress creates a prolonged reaction in the body where a relapse or worsening of these ME symptoms occur and can last for days, weeks, months or longer.
- Many people who have pushed far too hard beyond their limits have severely deteriorated and become permanently carer dependent. Managing ME to maintain an optimal baseline of illness requires avoiding PENE as much as possible. The push/crash cycle is very dangerous and can lead to a lower baseline.
- Worsening symptoms in ME as a result of Post Exertional Neuroimmune Exhaustion -PENE may include exhaustion, extreme chronic pain, cognitive dysfunction, unrefreshing sleep, headaches, migraines, muscle pain and muscle fatigability, orthostatic intolerance, neurally mediated hypotension, or POTS, inability to eat, swallow or digest food, paralysis as seen in Severe ME and many more debilitating symptoms.
- PENE is often described as a loss of stamina and/or functional capacity.
- PENE is not a subjective worsening of symptoms; it is an objective worsening and deterioration of ME, including worsening of symptoms and functional baseline.
- In some cases PENE may lead to a permanent more severe form of the illness.
- ME has one of the lowest scores for quality of life compared to many diseases. Avoiding PENE significantly improves health quality. Family, carers, medical professionals and others need to be supportive in order for patients to successfully avoid PENE as much as possible while still maintaining health and social supports.
Considerations for those with Severe and Very Severe ME.
Myalgic Encephalomyelitis (ME) is an acquired neurological disease with complex global dysfunctions. Pathological dysregulation of the nervous, immune and endocrine systems, with impaired cellular energy metabolism and ion transport are prominent features. Also all over body pain.
Overload phenomena is part of the complex pathophysiology of Severe ME as the body reacts to sensory inputs which it does not have the energy to manage. Those unfamiliar with the pathophysiology of ME mistakenly interpret this as ‘anxiety’, which it is not.
Minimising the need to ‘react’ is essential as reaction causes a physiological response which affects the already out of balance central and autonomic nervous systems. Being forced to react results in an exacerbation of symptoms.
It is important to realise that at the severe end of the spectrum people with Severe ME don’t need to exert themselves for the phenomenon PENE to operate, there can be a critical response to the slightest movement by the patient or by the movement of a visitor to the patient's bedroom. Even simple brain activity can lead to worsening of illness in ME, e.g., hearing noise from outside the bedroom.
For very severely affected ME sufferers there is virtually no ‘safe’ level of physical or mental activity, orthostatic stress or sensory input; no level which does not produce a worsening of symptoms, and perhaps also contribute to disease progression.
Due to the severity of illness in people with Severe and Very Severe ME, who would most likely be permanently confined to bed, care and treatment would be planned and catered to ensure that management of illness, dispensing of treatments and provision of meals and bathing is done in the most non-invasive way possible. As some Very Severe/Profound ME patients may be tube fed and administered meds intravenously there would be a very special care given to them.
The post exertion response crisis that occurs following any exertion, mental and physical, in Severe ME results in horrendous features such as paralysis, seizures, fits, unconciousness. Patients are often too ill to use a wheelchair or can only do so to a very limited degree. Many need to spend their time lying flat in silence and darkness to avoid deterioration. Some are tube-fed, incontinent, unable to communicate, allergic to medications, and unable to move.
Severe ME Case
Please see extract from Greg Crowhurst about caring for his wife Linda who has Severe ME; Greg highlights the need to be very careful to avoid the post exertion crisis response happening in Severe ME.
"I have cared day and night for my wife who has lain in unspeakable torment, torture and agony, for twenty-six years. The personal cost to us both because of M.E. has been enormous. People I have known, dying of cancer, have still enjoyed a better quality of life than my wife.Communication is broken on every level. As soon as she has spoken, she forgets what she has said. If I speak or ask a question it can cause unimaginable confusion and head-pain, shaking spasms, and deterioration.Literally everything hurts her and risks deterioration to partial or total paralysis. One wrong movement or noise and the whole day is ruined before it has begun. People simply do not understand.Who can possibly imagine living in such an assaulting and broken world for decades, without adequate investigation, care or support?We live in almost complete isolation, as my wife’s agony and hypersensitivities are so intense, that she cannot bear contact or interaction. I have had to learn to take a Moment by Moment approach, to ensure the need is met in the right moment in the right way.
Every aspect of care, including how and when I move, how and when I act, how and when I speak, not just in the room – for it still has impact in any part of the house – needs to be carefully thought through and brought into my awareness. We can never do the things other people take for granted, like: go on holiday, out for a meal, a coffee at a cafe, a show, a concert, a film, to see a band, for a walk together with the dog, cycle, shop, sail, swim, play games, like badminton, tennis, or volleyball, walk hand in hand, entertain friends, have dinner parties, go to church, although our faith is immensely important to us.
I have had to learn to take a 'Moment by Moment Approach', to ensure the need is met in the right moment in the right way. This is much harder than it sounds and needs the rightattitude, a person-centred, partnership approach, understanding and focus.
My wife cannot: read a book, play guitar, study or, learn, listen to the radio, follow conversation or engage in normal two-way conversation, have anyone in the house due to perfume, noise and movement sensitivity, tolerate virtually any contact at all, have anyone making noise in the room with her, bear even the simplest thing like having a cuddle or holding hands, find rest ever, for rest increases her physical suffering.
Our days are spent, without exception, struggling to cope from moment to moment in the most awful suffering anyone could imagine; except you couldn’t possibly imagine just how bad it is."
How to Try To Avoid the Post Exertion Response/Crisis in Severe ME
It is vital that those who are most ill – especially the estimated 2% of M.E. patients diagnosed with Very Severe M.E. – are recognised, kept safe from wrong treatment and misinterpretation, protected from further deterioration or needless suffering, and cared for in the most appropriate way."
People with Severe Myalgic Encephalomyelitis require unique care due to the tendency for the illness to be exacerbated by everyday stimuli such as light, noise and movement.
For people with Very Severe ME 'resting' implies 'complete incapacitation’ which means that inactivity is the only option. Those severely ill are often incapacitated because it is physically impossible for them to do anything else. Lying down in a dark room in silence and with absolute zero sensory input, with absolute zero physical movement or cognitive activity. Clothing and bed linen must be comfortable but sometimes no clothing is preferred and particular materials for bed linen essential.
The room must have a very moderate temperature; not too hot or too cold. There must be no internal or external noises.
Please see Greg's 'Moment By Moment Approach' guide here
Informal Survey
The onset of Post Exertional Neuroimmune Exhaustion - PENE can occur immediately, hours later or delayed up to 24-72 hours and depending on ME severity can last days, weeks, or even months.
We explored the differences between patients in an informal survey during May awareness month 2023. The survey feedback shows differences among ME patients in the response time for PENE to occur and to last, and the differences an individual may have, showing that most with ME don't have a set pattern re PENE occurring or with regards to how long symptoms associated with PENE will last.
Unfortunately we did not have an adequate response from the hard to reach Severe ME community.
See the responses to the survey question about the features of PENE below:
Does PENE (also referred to as PEM) happen straight away or minutes after exertion or hours after exertion or a day or more after exertion?Responses here
Post Exertional Neuroimmune Exhaustion - PENE Vs Fatigue
There is great importance in recognising Post Exertional Neuro-immune Exhaustion (PENE), when it comes to diagnosing Myalgic Encephalomyelitis (ME). There is a significant difference between what a healthy person experiences after activity and what a person with ME experiences.
The use of the same word ‘fatigue’ for both experiences often leads to endless misunderstandings and as a consequence can have a whole series of profound impacts on the person with ME and especially on those with Severe ME .
Post-Exertional Neuroimmune Exhaustion (PENE) as described in the International Consensus Criteria, guidelines for diagnosis and management
As per the International Consensus Criteria (ICC) 2011, a patient will meet the criteria for (A) post exertional neuroimmune exhaustion, (B) at least one symptom from three neurological impairment categories, (C) at least one symptom from three immune/gastro‐intestinal/genitourinary impairment categories, and (D) at least one symptom from energy metabolism/transport impairments.
(A) Post exertional neuroimmune exhaustion (PENE) is the cardinal criterion for a diagnosis of ME according to the International Consensus Criteria (2011) on ME.
PENE means when you suffer from Myalgic Encephalomyelitis (ME) your symptoms get worse after you do things, and even after you do the smallest thing.
You may start to feel worse immediately afterwards or several days later. You may feel worse for a short time, or a long time, or indefinitely.
Some people experience worsened symptoms after light activity such as brushing teeth, walking to the bathroom, or after mental activity such as reading, chatting on the phone or watching tv. Some people can suffer PENE by just sitting up in bed or from the smallest movement like turning their head.
Essentially any action whether physical, cognitive, emotional, social, etc, drains available energy and if the ability to replace this energy is impaired this can lead to a worsening of all symptoms which can last for days, weeks or months – even causing permanent, non-recoverable systemic damage.
Assessment and Diagnosis of ME as per the International Consensus Criteria )(ICC)
As mentioned already, Post-Exertional Neuroimmune Exhaustion (PENE) is a compulsory criteria in the diagnosis of ME. This cardinal feature is a pathological inability to produce sufficient energy on demand with prominent symptoms primarily in the neuroimmune regions.
Meaning - My body does not produce enough energy.
Characteristics are:
1. Marked, rapid physical and/or cognitive fatigability in response to exertion, which may be minimal such as activities of daily living or simple mental tasks, can be debilitating and cause a relapse.
Meaning - After I do physical things, I feel worse or after I read or write or do other mental tasks, I feel worse. In Severe/Very Severe/Profound ME after I carried out the smallest movement while lying motionless in bed I feel profound and debilitating symptoms.
2. Post-exertional symptom exacerbation: e.g. acute flu-like symptoms, pain and worsening of other symptoms.
Meaning - After I do things, I feel like I have the worst flu, or feel pain, or feel worse in other ways. In Severe/Very Severe/Profound ME I feel extreme widespread pain, profound multiple sensitivities, shaking, trembling, paralysis and other extreme symptoms.
3. Post-exertional exhaustion may occur immediately after activity or be delayed by hours or days.
Meaning - I may not feel worse right away. I may start to feel worse in a few hours, or the next day, or the day after that. In Severe/Very Severe/Profound ME I can feel immediately worse.
4. Recovery period is prolonged, usually taking 24 hours or longer. A relapse can last days, weeks or longer.
Meaning - I can feel worse for a day, or for a few days, or for a few weeks, or longer.
5. Low threshold of physical and mental fatigability (lack of stamina) results in a substantial reduction in pre-illness activity level.
Meaning - I can no longer do the things I used to be able to do.
6. Cognitive fatigability in response to exertion.
Meaning- After I do things, I may feel worse physically or mentally. I may have problems with memory or concentration.
Information on PENE is based on the information provided in the International Consensus Criteria ICC 2011
 |
| Image by JS |
Causes of Post Exertional Neuro-Immune Exhaustion (PENE) in Myalgic Encephalomyelitis (ME)
- Physical over-exertion
- Mental over-exertion
- Emotional over-exertion
- Sleep dysregulation
- Unbalanced/poor diet and nutrition
- Other medical issues
How to Prevent Post Exertional Neuro-Immune Exhaustion (PENE) in Myalgic Encephalomyelitis (ME)
There are a few ways to prevent PENE and to manage ME symptoms. There is no single way of managing ME that works for everyone, and it takes time to figure out what works best for you. There are several management options. Early diagnosis, taking medication to control certain symptoms, and making lifestyle changes can all help. See more options below.
- Early Diagnosis and appropriate rest in the early stages of the illness.
- Pacing (activity management) & Resting
- Energy Envelope Technique - staying within your energy envelope
- Medical Treatments
- Management strategies e.g., Ensure good nutrition and appropriate sleep
- Using a Heart Rate Monitor
- Managing relapses and adrenaline surges in ME
- Learn your health patterns
- Practice techniques like meditation if you can
- Build your support community e.g., family, carers, doctors, specialists
- Maintain emotional health
- Avoid stress
- Treat other medical conditions
- Management of ME as per the International Consensus Primer, the ICP 2012
There are more details on each item in the above list of ways to prevent PENE and ways to manage ME symptoms here
Trial and Error
Management techniques mentioned above can help relieve some symptoms, but this is a matter of trial and error; the illness has an individual element - what helps one person might not work for the next. Your GP and/or specialist can help with a range of issues, including sleep disturbance, coping with pain and energy management.
.jpg)
More on Assessing the Post Exertional Response in ME
1. The CPET Test
(only suitable for some people with mild & moderate ME)
The distinctive element of PENE often described as a loss of stamina and/or functional capacity is referred to in the results of the 2-day cardiopulmonary exercise test (CPET) procedure.
The CPET is a procedure which assesses exercise capacity and recovery by performing two exercise tests 24 hours apart. The hypothesis is that ME patients display a characteristic deterioration in exercise capacity on the second test, a finding that has been reported by multiple research groups. This test is considered the gold standard for measuring physical capacity.
A CPET is usually reproducible and normally has a test-retest difference of 7-12%. ME patients however show strikingly lower results on several measures at the second CPET compared to the first, despite meeting objective markers of maximal effort. The drop in functional capacity on the second CPET is usually not seen in other diseases.
According to Keller et al. (2014), “ME patients currently represent a unique class of ill patients who do not reproduce maximal CPET measures, unlike individuals with cardiovascular disease, lung disease, end-stage renal disease pulmonary arterial hypertension and cystic fibrosis".
A preliminary study from New Zealand suggests that patients with MS do not display the same decline on the second day of exercise testing, as do patients with ME.
“Once the disease was established the most characteristic symptom was extreme exhaustion, particularly after exercise. The exhaustion also occurred after emotional or mental strain.”
The CPET Test: "Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis (ME) "
2. De Paul DSQ-PEM Questionnaire
Assessments using tools such as self-reporting questionnaires, e.g. DSQ-PEM questionnaire by De Paul could be used where the CPET test may not be available to clinicians or where it is not practical for those with ME, especially people with severe ME. The questionnaire is a valuable tool for all severities to evidence PEM/PENE. Link here: DSQ-PEM Questionnaire
3. Simple Self Assessment
Ask yourself or the ME patient the following questions to simply assess PENE
What kind of exertion triggers your PENE?
Does PENE happen
minutes after exertion
hours after exertion
a day or more after exertion
not at all
Please describe what happens to you when PENE occurs
How long does it take you to recover from PENE?
at least a day
several days
at least a week
several weeks
a month or more
- What do you do to recover from PENE?
What do you do to prevent PENE from occurring?
4. Using a Heart Rate Monitor
Energy production is not normal in ME. Even minimal everyday tasks can exacerbate illness and prolong recovery time.
People with ME have a low anaerobic threshold which can decrease further after activity. Pacing with a heart rate monitor (HRM) interrupts the push-crash cycle and helps to prevent PENE.
Please see the Workwell Foundation's factsheet about heart rate monitoring here and further information in our post about Managing ME here. (Workwell Foundation refer to the post exertion response in ME as PEM, as do others; we use and promote the use of the label PENE as per the ICC)
Please Note
Questions raised about the clinical use of the 2-day CPET procedure in those with Severe ME by Snell et al (2013) suggested it might be unethical to use this method since many ME patients might suffer a serious relapse as a result of exercise performance. Other methods such as Heart Rate Monitoring or the De Paul DSQ-PEM Questionnaire are more suitable to those with more severe forms of ME.
It is important to recognise that at the severe end of the spectrum people with Severe and Profound ME don’t need to exert themselves for the phenomenon PENE to operate, it can simply be caused by an attempt to read a book, watching tv or listening to a visitor. There can be a critical response to the slightest movement by the patient or by the movement of a visitor to the patient's bedroom. Even simple brain activity can lead to worsening of illness in ME, e.g., hearing noise from outside the bedroom.Even simple brain activity can lead to worsening of illness in ME.
For very severely affected ME sufferers there is virtually no ‘safe’ level of physical or mental activity, orthostatic stress or sensory input; no level which does not produce a worsening of symptoms, and perhaps also contribute to disease progression.
.jpg)
Survey Feedback - The Post Exertional Neuro-immune Exhaustion (PENE) feature in ME
We held an informal survey during May awareness month 2023 to find out more about patients' individual experiences with regards to Post Exertional Neuro-Immune Exhaustion - PENE.
Here are the questions we asked:
Q1 What words do you use to describe PENE (also referred to as PEM), the response you have after exertion whether physical or mental exertion or in response to a hyper sensitivity stimulus or action, e.g. 'relapse' ?
Q2 What kind of exertion triggers your PENE/PEM?
Q3 Does PENE (also referred to as PEM) happen... straight away or minutes after exertion or hours after exertion or a day or more after exertion?
Q4 How do you avoid PENE (or PEM), the post exertion response/crisis?
Q5 What can you do to recover from PENE, the post exertion response/crisis?
Q6 If you could provide one piece of advice to a person newly diagnosed with ME or to someone who suspects ME what would it be?
Please see the feedback from an informal survey on Post Exertional Neuro-Immune Exhaustion - PENE which we held during ME awareness month 2023 here
The Science Behind Post Exertional Neuro-Immune Exhaustion (PENE) in Myalgic Encephalomyelitis (ME)
1. Symptoms in ME are made worse due to physical or cognitive exertion
The Jason et al 2019 study entitled, ‘Assessment of Post-Exertional Malaise (PEM) in Patients with Myalgic Encephalomyelitis (ME)’ refers to a list of symptoms in ME which are potentially made worse due to physical or cognitive exertion. See the full study based on feedback from 1534 patients who responded to questions about PEM here
Table 4. from the study by Leonard Jason et al shows a list of symptoms caused or made worse by exertion, see below.
| Items | % (n) “Yes” | % (n) at “2” Threshold | Mean (SD) |
|---|---|---|---|
| 1. Reduced stamina and/or functional capacity | 99.4 (1525) | 98.0 (1504) | 90.60 (17.16) |
| 2. Physical fatigue | 98.9 (1517) | 98.3 (1508) | 87.53 (18.26) |
| 3. Cognitive exhaustion | 97.4 (1494) | 92.0 (1412) | 77.64 (24.87) |
| 4. Problems thinking | 97.4 (1494) | 92.6 (1420) | 78.47 (24.87) |
| 5. Unrefreshing sleep | 95.0 (1457) | 91.1 (1398) | 80.57 (27.65) |
| 6. Muscle pain | 87.9 (1349) | 81.5 (1250) | 69.41 (33.95) |
| 7. Insomnia | 87.3 (1339) | 75.1 (1152) | 62.40 (34.30) |
| 8. Muscle weakness/instability | 87.3 (1339) | 77.2 (1185) | 64.03 (33.86) |
| 9. Temperature dysregulation | 86.9 (1333) | 75.2 (1153) | 63.76 (34.75) |
| 10. Flu-like symptoms | 86.6 (1329) | 74.4 (1142) | 59.52 (33.43) |
| 11. Aches all over your body | 85.6 (1313) | 79.5 (1219) | 68.68 (35.58) |
| 12. Physically fatigued while mentally wired | 82.1 (1259) | 72.8 (1116) | 59.00 (35.65) |
| 13. Dizziness | 80.7 (1238) | 56.0 (859) | 46.28 (33.19) |
| 14. Gastro-intestinal problems | 78.6 (1206) | 59.3 (910) | 49.90 (36.02) |
| 15. Headaches | 78.0 (1197) | 56.5 (866) | 46.48 (34.52) |
| 16. Ataxia | 77.6 (1191) | 57.8 (886) | 47.62 (35.18) |
| 17. Increased heart rate/heart palpitations | 77.4 (118) | 64.9 (996) | 52.28 (36.51) |
| 18. Weak or stiff neck | 74.6 (1144) | 61.0 (936) | 51.35 (38.20) |
| 19. Joint pain | 73.0 (1120) | 59.5 (912) | 49.17 (37.86) |
| 20. Problems with speech | 72.4 (1110) | 50.0 (767) | 40.22 (33.14) |
| 21. Sore throats | 70.9 (1087) | 47.2 (724) | 38.92 (33.55) |
| 22. Muscle twitching | 68.1 (1045) | 40.9 (627) | 35.12 (32.38) |
| 23. Night sweats and chills | 67.7 (1038) | 46.9 (720) | 38.48 (34.69) |
| 24. Sore eyes | 67.0 (1028) | 49.0 (752) | 39.91 (35.70) |
| 25. Nerve pain | 63.3 (971) | 48.8 (748) | 40.65 (38.16) |
| 26. Sore lymph nodes | 62.9 (965) | 44.0 (675) | 36.36 (35.28) |
| 27. Nausea | 62.2 (954) | 38.1 (584) | 31.89 (32.13) |
| 28. Tinnitus | 60.3 (925) | 39.8 (611) | 37.42 (38.96) |
| 29. Trouble breathing | 57.8 (887) | 40.9 (628) | 33.97 (35.67) |
| 30. Neurological symptoms | 57.0 (875) | 42.8 (656) | 34.60 (36.14) |
| 31. Excessive sleep | 54.4 (835) | 44.5 (682) | 36.23 (38.58) |
| 32. Loss of appetite | 49.0 (752) | 30.9 (474) | 25.41 (31.62) |
| 33. Migraines | 46.2 (708) | 24.6 (378) | 21.92 (29.27) |
| 34. Cardiac pain and/or arrhythmia | 41.2 (632) | 24.8 (381) | 21.12 (30.30) |
| 35. Brain twangs | 29.9 (459) | 17.7 (272) | 15.00 (26.82) |
| 36. Severe burning sensation all over skin | 29.7 (456) | 18.3 (280) | 15.96 (28.87) |
| 37. Paralysis/inability to move | 29.4 (451) | 9.4 (144) | 11.49 (21.91) |
| 38. Premenstrual symptoms | 21.1 (323) | 16.4 (251) | 13.56 (29.25) |
| 39. Decreased heart rate | 15.1 (231) | 7.4 (114) | 6.88 (19.09) |
 |
| Image by JS |
2. Scientific Papers behind PENE compiled by Dr Mark Gutheridge
A study by the Workwell Foundation et al shows that ME patients have metabolic defects that cannot be explained by exercise phobias, deconditioning or 'illness beliefs'. People with ME have reduced oxygen consumption during exercise tests.
Properties of measurements obtained during cardiopulmonary exercise testing in individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome - IOS Press
People with ME have an impaired ability to increase their oxygen consumption during exercise. This is entirely different to every other disease we know including cardiovascular disease, lung disease, end-stage renal disease, hypertension & cystic fibrosis.
People with ME also show impaired oxygen consumption and reduced anaerobic threshold compared to Multiple Sclerosis.
Exercise testing provides an explanation for why people with ME can crash even after modest exertion. The reduced aerobic capacity of people with ME results in a switch to anaerobic metabolism that likely impacts their ability to do simple daily activities.
ME patients can 'crash' if they over-exert resulting in a post-exertional malaise (PEM). Triggering PEM reduces the threshold at which anaerobic metabolism accelerates which impairs the ability of patients to do non-strenuous tasks.
And exercise that triggers PEM in ME patients leads to a sustained immune inflammatory response that is distinct from that in sedentary or deconditioned people.
People use aerobic metabolism for the majority of daily activities such as walking and seated tasks, but a reduced aerobic capacity of ME patients likely forces a switch to less efficient anaerobic metabolism leading to premature fatigue and PEM.
Exercise studies also show that the increased reliance on anaerobic metabolism in ME patients results in increased metabolites such as lactic acid which likely leads to an inability to maintain work and a reduction in activity.
Physical therapists should be aware that post-exertional malaise (PEM) in people with ME is due to objectively measurable deficits in metabolism.
So yes, exercise is beneficial for nearly every illness.....but the science shows that ME is the exception.
This Frontiers review by Workwell discusses how cardiopulmonary exercise testing (CPET)can be used to help diagnose & research ME.
Frontiers | Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (frontiersin.org)
Frontiers | Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (frontiersin.org)
Included in the study is Table 1. which provides a helpful list of definitions for patients and doctors to investigate ME.
%20should%20be%20based%20on%20the%20characteristic%20clinical%20feature%20Post-Exertional%20Neuro%20Immune%20Exhaustion%20(PENE),%20the%20cardinal%20feature%20of%20ME.%20It%20is%20sometimes%20also%20called%20%E2%80%98payb%20(1).jpg)
The Problems that arise when the Science of ME is Ignored
Myalgic Encephalomyelitis (ME), & PENE in ME has long been misunderstood, derided & ignored. Believing this illness can be cured by attitude & effort is stigmatizing, harmful for individuals who blame themselves or get blamed for their suffering, & for the community of people deeply affected.
PENE is not ......
‘exaggerating’‘imagining it’‘aging’‘depression’‘menopause’‘laziness’‘being overweight’‘normal, everyone gets tired’‘anxiety’‘work refusal’‘psychiatric’‘exercise intolerance’‘a woman’s illness’‘extreme tiredness’‘hysteria’‘mental illness’‘MUS’‘chronic fatigue’‘deconditioning’‘perfectionism’‘conversion disorder’‘psychosomatic’‘middle age issue’‘Munchausen syndrome by proxy’‘school avoidance’‘emotionally distressed’‘anti-science’‘anti-medics’‘activists’‘hypochondriac’
“ME patients describe post–exertional malaise as all-encompassing with symptoms affecting every part of the body, difficult to predict or manage, and requiring complete bedrest to fully or partially recover.”
 |
| Image by JS |
Resources
‘Dialogues For a Neglected Illness’
The short films about PENE, referred to as PEM, ‘A Brief Guide to PEM’, ‘Understanding PEM’ and 'Patients' Accounts of Symptoms - Post Exertional Malaise' from ‘Dialogues for a neglected illness’ (Dialogues for ME) raise awareness of the effects of activity/exertion within ME, in particular within the severe category, how some may be affected by pottering for an hour whereas for others the slightest exertion such as thinking of trying to read, will trigger PENE.The films show how exertion does not necessarily need to be what would normally be described as exertion, yet can still have a deteriorative impact leading to a worsening of symptoms.The films portray reality where at the severe end of the spectrum people with Severe ME don’t need to exert themselves for the phenomenon PENE to operate, it can simply be caused by reading a book or listening to a visitor, even simple brain activity can lead to worsening of illness in ME.A common characteristic of PENE described is that it can be elicited by multiple types of triggers.Films available here: Post-Exertional Malaise - Dialogues (dialogues-mecfs.co.uk)
Avoiding PENE
Using a Pulse Oximetre
'Using a Pulse Oximetre' is a two-page document by ME International, please access here
First Aid
'First Aid' for M.E. Energy Systems' - Heart Rate Monitoring, information compiled by ME Advocates Ireland. please access here
'What a failure of our medical “system” that people go years with PEM and no one puts the pieces together for them. I can’t even conceive of the othering my patients have to live with daily but I’m reminded every time a patient cries when we simply discuss the science of PEM.'
~ Todd Davenport, Professor & Vice Chair, Department of Physical Therapy, University of the Pacific Stockton, California, US
Disclaimer: The information in this post is for general information purposes only. While we endeavour to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the post or the information, products, services, etc contained in the post for any purpose. Any reliance you place on such information is therefore strictly at your own risk.The suitability of any solution is totally dependent on the individual. It is strongly recommended to seek professional advice and assistance.
No comments:
Post a Comment