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Post-exertional malaise
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=== Asking the right questions === [[Leonard Jason|Jason]] et al. (1999) reported that in a group of ME/CFS patients, the percentage endorsing PEM ranged from 40,6 to 93,8% depending on how the question assessed this symptom.<ref name="Jasonblog2012">{{Cite web|url=https://www.meassociation.org.uk/2012/04/to-pem-or-not-to-pem-that-is-the-question-for-case-definition-research-1st-website-27-april-2012/ | title = To PEM or not to PEM? That is the question for case definition {{!}} Research 1st website | date = 27 April 2012 | website = Research first blog|language=en-US|access-date=2018-10-10 | last= Jason | first = Leonard | authorlink = Leonard Jason | last2 =Evans | first2 =Meredyth | authorlink2 = Meredyth Evans}}</ref> The report of the National Academy of Medicine noted that “the prevalence of PEM among ME/CFS patients as diagnosed by existing criteria varies from 69 to 100 percent.”<ref name="IOM2015" /> Some patients try to reduce post-exertional relapses by [[pacing]] themselves and reducing exertion that exceeds their energy limits. Questionnaires assessing PEM by frequency instead of propensity, might erroneously label these patients as not having PEM. In a 2015 study, Jason et al. measured ME/CFS patients’ responses to the PEM-criterion in the [[Fukuda criteria|Fukuda (1994)]] definition: ‘Do you feel generally worse than usual or fatigued for 24 hours or more after you have exercised?’ Although the majority (75%) endorsed this item, a notable percentage (25%) did not. Yet when the question was framed differently, leaving out the 24 hours’ time period and substituting exercise with normal daily activity, these participants also agreed they experienced high levels of fatigue after normal daily activity.<ref name="Jason2015" /> This clearly shows that patients who have already modified their activities to avoid or reduce PEM may potentially show up as false negatives. Another issue is the definition of PEM in the Fukuda criteria. While the wording used here is vague, the time criterion is rather strict requiring PEM to last more than 24 hours.<ref name="fukuda1994" /> Some patients do not endorse this item because they only have post-exertional malaise for less than 24 hours.<ref name="Jason1999">{{Cite journal | last= Jason | first = Leonard A. | author-link = Leonard Jason | last2 = King | first2 = Caroline P. | last3 = Richman | first3 = Judith A. | last4 = Taylor | first4 = Renee R. | authorlink4 = Reneé Taylor | last5 = Torres | first5 = Susan R. | last6 = Song | first6 = Sharon | date = Jan 1999 | title = U.S. Case Definition of Chronic Fatigue Syndrome|url=https://www.tandfonline.com/doi/abs/10.1300/J092v05n03_02?journalCode=icfs20|journal=Journal of Chronic Fatigue Syndrome|language=en|volume=5|issue=3-4|pages=3–33|doi=10.1300/j092v05n03_02|issn=1057-3321}}</ref> A 2018 study concluded that setting the criterion at 24 hours would exclude almost 30% of ME/CFS patients. It advises that this definition might be useful in research settings but that in a clinical context, a 14-23 hour time period might be more appropriate.<ref name="Cotler2018">{{Cite journal | last = Cotler | first=Joseph | last2 = Holtzman | first2 = Carly | last3 = Dudun | first3 = Catherine | last4 = Jason | first4 = Leonard A. | date = 2018-09-11 | title = A Brief Questionnaire to Assess Post-Exertional Malaise|url=https://www.ncbi.nlm.nih.gov/pubmed/30208578|journal=Diagnostics (Basel, Switzerland)|volume=8|issue=3|doi=10.3390/diagnostics8030066|issn=2075-4418|pmid=30208578}}</ref> These observations point to the need of a more precise definition of PEM and several attempts to this end have been made.
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