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Post-exertional malaise
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== Symptom recognition == === Case definitions === Early descriptions of symptom exacerbation in [[Myalgic encephalomyelitis|ME]] focused on post-exertional muscle weakness. Renowned ME-expert [[Melvin Ramsay]] for example wrote: <blockquote>"[[Muscle fatigability]] whereby, even after a minor degree of physical effort, three, four or five days or longer elapse before full [[muscle]] power is restored is unique and constitutes the sheet anchor of diagnosis. Without it I would be unwilling to diagnose a patient as suffering from ME."<ref name="Ramsay1988">Ramsay M. (1988). Myalgic Encephalomyelitis and Postviral Fatigue States: The Saga of Royal Free Disease. Gower Medical Publishing. Second edition.</ref> </blockquote>In a 1985 study [[Peter Behan|Behan]] et al. noted that all of their patients “had the same primary symptom that of gross fatigue made worse by exercise".<ref name="Behan1985">{{Cite journal | last = Behan | first=P. O. | last2 = Behan | first2 = W.M. | last3 = Bell | first3 = E.J. | date = May 1985 | title = The postviral fatigue syndrome - an analysis of the findings in 50 cases|url=https://www.ncbi.nlm.nih.gov/pubmed/2993423|journal=The Journal of Infection|volume=10|issue=3|pages=211–222|issn=0163-4453|pmid=2993423}}</ref> ====Formerly used to define Chronic fatigue syndrome==== In the 1988 [[Holmes criteria]] for [[Chronic fatigue syndrome|CFS]], unexplained generalized [[muscle weakness]] was one of the 11 minor symptoms, yet it was fatigue that set the tone. Another minor symptom referred to "prolonged (24 hours or greater) generalized fatigue after levels of [[exercise]] that would have been easily tolerated in the patient's premorbid state".<ref name="Holmes1988">{{Cite journal | last = Holmes | first = G. P. | last2 = Kaplan | first2 = J.E. | last3 = Gantz | first3 = N.M. | last4 = Komaroff | first4 = A.L. | last5 = Schonberger | first5 = L.B. | last6 = Straus | first6 = S.E. | last7 = Jones | first7 = J.F. |last8 = Dubois | first8 = R.E. | last9 = Cunningham-Rundles | first9 = C. | date = Mar 1988 | title = Chronic fatigue syndrome: a working case definition|url=https://www.ncbi.nlm.nih.gov/pubmed/2829679|journal=Annals of Internal Medicine|volume=108|issue=3|pages=387–389|issn=0003-4819|pmid=2829679}}</ref> PEM is not a mandatory symptom under the Holmes definition. The wording "postexertional malaise" was used in the article Symptoms and signs of chronic fatigue syndrome by Anthony Komaroff and Dedra Buchwald, from 1991.<ref>{{Cite journal|title=Symptoms and Signs of Chronic Fatigue Syndrome|date=1991-01-01|url=http://academic.oup.com/cid/article/13/Supplement_1/S8/423106/Symptoms-and-Signs-of-Chronic-Fatigue-Syndrome|journal=Clinical Infectious Diseases|volume=13|issue=Supplement_1|pages=S8–S11|last=Komaroff|first=Anthony L.|last2=Buchwald|first2=Dedra|language=en|doi=10.1093/clinids/13.Supplement_1.S8|issn=1537-6591}}</ref> The wording "postexertional malaise" was used as one of the 8 minor symptoms in the 1994 [[Fukuda criteria]], but without further clarification of the term, except that it lasts more than 24 hours. PEM is not a mandatory symptom under the Fukuda criterion. ====Retired criteria for Chronic fatigue syndrome==== The [[Oxford criteria]] has been retired from use after a number of [[Oxford_criteria#Criticisms|scientific critcisms]] were raised, including that it does not list PEM as a requirement or even a symptom.<ref name="P2PPreview2015">{{Cite journal | last = Haney | first = Elizabeth | last2 = Smith | first2 = M.E. Beth | last3 = McDonagh | first3 = Marian | last4 = Pappas | first4 = Miranda | last5 = Daeges | first5 = Monica | last6 = Wasson | first6 = Ngoc | last7 = Nelson | first7 = Heidi D. | date = Jun 16, 2015 | title = Diagnostic Methods for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop | url = http://annals.org/article.aspx?doi=10.7326/M15-0443|journal=Annals of Internal Medicine|language=en|volume=162|issue=12 | pages = 834|doi=10.7326/m15-0443|issn=0003-4819|via=}}</ref> Patients with the symptom of [[fatigue]], which many illnesses and diseases have, are incorrectly given the CFS diagnosis in research studies when the [[Oxford criteria]] is used. <blockquote>The [[United States]] [[National Institutes of Health]] (NIH) has issued a draft report that highlights the dire need for scientific research that will help find a cure for the millions of people suffering from [[ME/CFS|myalgic encephalomyelitis/chronic fatigue syndrome]] (ME/CFS) worldwide. The report also highlights the fact that the decades-old UK Royal Society of Medicine’s Oxford criteria for ME/CFS are severely “flawed,” and that continuing to use these criteria may “cause harm.” Further, the NIH report says that the Royal Society definition should “be retired” and replaced with a single case definition agreed to by the ME/CFS community.<ref name="Oxfordscrapped">{{Cite web|url=http://theargusreport.com/us-nih-report-calls-uk-definition-mecfs-scrapped/ | title = US NIH Report Calls for UK Definition of ME/CFS to be Scrapped | last = Swift | first=Penny | date = 2015-01-16 | website = The Argus Report|language=en-US|access-date=2019-02-28}}</ref></blockquote> {{See also|Oxford criteria}} ====Currently used as the hallmark symptom defining ME/CFS==== Post-exertional malaise was recognized as a symptom of [[chronic fatigue syndrome]] in the 1994 [[Fukuda criteria]], but did not fully describe it, and only identified it as an optional symptom.<ref name="fukuda1994">{{Cite journal | last = Fukuda | first = K. | author-link = Keiji Fukuda | last2 = Straus | first2 = S.E. | authorlink2 = Stephen Straus | last3 = Hickie | first3 = I. | authorlink3 = Ian Hickie | last4 = Sharpe | first4 = M.C. | authorlink4 = Michael Sharpe | last5 = Dobbins | first5 = J.G. | authorlink5 = James Dobbins | last6 = Komaroff | first6 = A. | authorlink6 = Anthony Komaroff | date = 1994-12-15 | title = The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group | url = https://www.researchgate.net/profile/Michael_Sharpe2/publication/247808895_The_Chronic_Fatigue_Syndrome_A_Comprehensive_Approach_to_Its_Definition_and_Study/links/0c96053201643bfc4b000000/The-Chronic-Fatigue-Syndrome-A-Comprehensive-Approach-to-Its-Definition-and-Study.pdf|journal=Annals of Internal Medicine|volume=121|issue=12 | pages = 953–959|issn=0003-4819|pmid=7978722|via=|publisher=American College of Physicians}}</ref> The 2003 [[Canadian Consensus Criteria]] (CCC) for ME/CFS used PEM as the key compulsory symptom for diagnosis. The CCC's were the first criteria to stress that the onset of PEM could be delayed and to describe its debility as a [[flu-like symptoms|flu-like distress]].<ref name="CCC">{{Cite journal | last = Carruthers | first = Bruce M. | last2 = Jain | first2 = Anil Kumar | last3 = De Meirleir | first3 = Kenny L. | last4 = Peterson | first4 = Daniel L. | last5 = Klimas | first5 = Nancy G. | last6 = Lerner | first6 = A. Martin | last7 = Bested | first7 = Alison C. | last8 = Flor-Henry | first8 = Pierre | last9 = Joshi | first9 = Pradip | date = Jan 2003 | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome|url=https://www.tandfonline.com/doi/abs/10.1300/J092v11n01_02|journal=Journal of Chronic Fatigue Syndrome|language=en|volume=11|issue=1 | pages = 7–115|doi=10.1300/j092v11n01_02|issn=1057-3321}}</ref> [[Canadian Consensus Criteria#Definition|PEM and/or post-exertional fatigue]] is a mandatory symptom under the CCC criterion.<ref name="CCC-overview">{{Cite web|url=http://www.investinme.org/Documents/PDFdocuments/Canadian_ME_Overview_A4.pdf | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Clinical Case Definition and Guidelines for Medical Practitioners - An Overview fo the Canadian Consensus Document | last = Carruthers | first = Bruce | authorlink=Bruce Carruthers | last2 = van de Sande | first2 = Marjorie | authorlink2 = Marjorie van de Sande | date = |website=Invest in ME Research | pages = 4|type=|archive-url=|archive-date=|url-status=|access-date=|quote=Physical or mental exertion often causes debilitating malaise and/or fatigue, generalized pain, deterioration of cognitive functions, and worsening of other symptoms that may occur immediately after activity or be delayed. Patients experience rapid muscle fatigue and lack endurance.}}</ref> The [[International Consensus Criteria]] for [[myalgic encephalomyelitis |ME]] replaced post-exertional malaise with a similar symptom of [[post-exertional neuroimmune exhaustion]], though this criteria is rarely used in clinical practice.<ref name="ICC" /> The [[National Academy of Medicine]] 2015 report describes PEM more generally as "an exacerbation of some or all of an individual's ME/CFS symptoms that occurs after physical or cognitive exertion and leads to a reduction in functional ability." The report confirmed PEM as the hallmark symptom of ME/CFS and advised to rename the disease accordingly to [[Systemic Exertion Intolerance Disease]] (SEID).<ref name="IOM2015" /> PEM is a mandatory symptom under the SEID criterion, which was adopted by the [[Centers for Disease Control|CDC]] and is used as the current ME/CFS criteria.<ref name="CDC-symptoms" /> The UK uses the [[NICE ME/CFS diagnostic criteria 2021|NHS diagnostic criteria]], which were changed in 2021 to use post-exertional malaise as the hallmark symptom a required (compulsory) symptom that is needed for ME/CFS to be diagnosed.<ref name="CDC-symptoms" /><ref name="GuidelinesChange2021" /> ====Currently used to define Myalgic encephalomyelitis==== In 2011, the [[International Consensus Criteria]] (ICC) introduced the new term '''[[post-exertional neuroimmune exhaustion|Post-Exertional Neuro-immune Exhaustion]] (PENE)''' to refer to the characteristic exercise and exertion intolerance of [[myalgic encephalomyelitis]] (ME) patients. It notes a [[delayed onset of post-exertional symptoms|delayed onset]] and [[Recovery period is prolonged, usually taking 24 hours or longer|prolonged recovery]], and uses acute [[flu-like symptoms]] to describe PENE. By definition PENE results in a [[Substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities|substantial reduction in functioning]], as even simple activities of daily living can cause a relapse.<ref name="ICC">{{Cite journal | last = Carruthers | first = Bruce M. | author-link = Bruce Carruthers | last2 = van de Sande | first2 = Marjorie I. | authorlink2 = Marjorie van de Sande | last3 = De Meirleir | first3 = Kenny L. | authorlink3 = Kenny De Meirleir | last4 = Klimas | first4 = Nancy G. | author-link4 = Nancy Klimas | last5 = Broderick | first5 = Gordon | author-link5 = Gordon Broderick | last6 = Mitchell | first6 = Terry | authorlink6 = Terry Mitchell | last7 = Staines | first7 = Donald | author-link7 = Donald Staines | last8 = Powles | first8 = A.C. Peter | author-link8 = A C Peter Powles | last9 = Speight | first9 = Nigel | authorlink9 = Nigel Speight | last10 = Vallings | first10 = Rosamund | authorlink10 = Rosamund Vallings | last11 = Bateman | first11 = Lucinda | authorlink11 = Lucinda Bateman | last12 = Baumgarten-Austrheim | first12 = Barbara | authorlink12 = Barbara Baumgarten-Austrheim | last13 = Bell | first13 = David | author-link13 = David Bell | last14 = Carlo-Stella | first14 = Nicoletta | author-link14=Nicoletta Carlo-Stella | last15 = Chia | first15 = John | author-link15 = John Chia | last16 = Darragh | first16 = Austin | author-link16 = Austin Darragh | last17 = Jo | first17 = Daehyun | author-link17 = Daehyun Jo | last18 = Lewis | first18 = Donald | author-link18 = Donald Lewis | last19 = Light | first19 = Alan | author-link19 = Alan Light | last20 = Marshall-Gradisnik | first20 = Sonya | author-link20 = Sonya Marshall-Gradisnik | last21 = Mena | first21 = Ismael | author-link21 = Ismael Mena | last22 = Mikovits | first22 = Judy | author-link22 = Judy Mikovits | last23 = Miwa | first23 = Kunihisa | author-link23=Kunihisa Miwa | last24 = Murovska | first24 = Modra | author-link24=Modra Murovska | last25 = Pall | first25 = Martin | author-link25=Martin Pall | last26 = Stevens | first26 = Staci | authorlink26 = Staci Stevens | date = 2011-08-22 | title = Myalgic encephalomyelitis: International Consensus Criteria|url=https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796.2011.02428.x|journal=Journal of Internal Medicine|language=en|volume=270|issue=4|pages=327–338|doi=10.1111/j.1365-2796.2011.02428.x|issn=0954-6820|pmc=3427890|pmid=21777306|via=}}</ref> PENE is a mandatory symptom under the ICC criterion. ====Long COVID ==== Post-exertional malaise is a potential symptom of [[Long COVID]] in the [[World Health Organization Long COVID diagnostic criteria|World Health Organization]]'s definition.<ref name="WHO-longcovid-criteria">{{citation | title = A clinical case definition of post COVID-19 condition by a Delphi consensus | date = Oct 6, 2021 |publisher=[[World Health Organization]] | others = World Health Organization (WHO) clinical case definition working group on post COVID-19 condition | first1 = Joan B. | last1 = Soriano | first2 = Maya | last2 = Allan | first3 = Carine | last3 = Alsokhn | first4 = Nisreen A. | last4 = Alwan | authorlink4 = Nisreen Alwan | first5 = Lisa | last5 = Askie | first6 = Hannah E. | last6 = Davis | authorlink6 = Hannah Davis | first7 = Janet V. | last7 = Diaz | first8 = Tarun | last8 = Dua | first9 = Wouter | last9 = de Groote | first10 = Robert | last10 = Jakob | first11 = Marta | last11 = Lado | first12 = John | last12 = Marshall | first13 = Srin | last13 = Murthy | first14 = Jacobus | last14 = Preller | first15 = Pryanka | last15 = Relan | first16 = Nicoline | last16 = Schiess | first17 = Archana | last17 = Seahwag | ref = WHO reference number: WHO/2019-nCoV/Post_COVID-19_condition/Clinical_case_definition/2021.1 | url = https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1}}</ref> ===Psychological paradigm === ====Dismissed as disturbed effort perceptions or kinesiophobia ==== [[File:Brian vastag.png|thumb|right|[[Brian Vastag]] is an American and award-winning journalist and an ME/CFS patient that won a disability case against Prudential, proving that PEM is a severe symptom that keeps him from gainful employment]] The existence of PEM as a distinctive and complex symptom of ME/CFS has been dismissed in early research into the disease. Some interpreted it as just fatigue after exercise<ref name="CDC-questionnaire">{{Cite web|url = https://www.cdc.gov/me-cfs/pdfs/symptom-inventory-questionnaire-508.pdf | title = Symptoms Inventory Questionnaire {{!}} 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>, while others saw it as an artifact of disturbed effort perceptions<ref name="Laurie1997">{{Cite journal | last = Lawrie | first = S. M. | last2 = Machale | first2 = S.M. | last3 = Power | first3 = M.J. | last4 = Goodwin | first4 = G.M. | date=Sep 1997 | title = Is the chronic fatigue syndrome best understood as a primary disturbance of the sense of effort?|url=https://www.cambridge.org/core/journals/psychological-medicine/article/editorial-is-the-chronic-fatigue-syndrome-best-understood-as-a-primary-disturbance-of-the-sense-of-effort/434A5EB2C5B4F971A4A36C1DC3400A7E|journal=Psychological Medicine|language=en|volume=27|issue=5 | pages = 995–999|issn=1469-8978}}</ref><ref>{{Cite journal | last = Rosen | first = S D | last2 = King | first2 = J C | last3 = Wilkinson | first3 = J B | last4 = Nixon | first4 = P G | date = Dec 1990 | title = Is chronic fatigue syndrome synonymous with effort syndrome?|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292947/|journal=Journal of the Royal Society of Medicine|volume=83|issue=12 | pages = 761–764|issn=0141-0768|pmc=1292947|pmid=2125315}}</ref><ref>{{Cite journal | last = Wallman | first = Karen E. | last2 = Sacco | first2 = Paul | date = Jan 2007 | title = Sense of effort during a fatiguing exercise protocol in chronic fatigue syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/17365951|journal=Research in Sports Medicine|volume=15|issue=1 | pages = 47–59|doi=10.1080/15438620601184331|issn=1543-8627|pmid=17365951}}</ref> or an [[Illness beliefs|irrational fear of movement]]<ref>{{Cite journal | last = Silver | first=A. | last2 = Haeney | first2 = M. | last3 = Vijayadurai | first3 = P. | last4 = Wilks | first4 = D. | last5 = Pattrick | first5 = M. | last6 = Main | first6 = C.J. | date = Jun 2002 | title = The role of fear of physical movement and activity in chronic fatigue syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/12069873|journal=Journal of Psychosomatic Research|volume=52|issue=6 | pages = 485–493|issn=0022-3999|pmid=12069873}}</ref><ref name="Fischler1997">{{Cite journal | last = Fischler | first=B. | last2 = Dendale | first2 = P. | last3 = Michiels | first3 = V. | last4 = Cluydts | first4 = R. | last5 = Kaufman | first5 = L. | last6 = De Meirleir | first6 = K. | authorlink6 = Kenny De Meirleir | date = Apr 1997 | title = Physical fatigability and exercise capacity in chronic fatigue syndrome: association with disability, somatization and psychopathology|url=https://www.ncbi.nlm.nih.gov/pubmed/9160276|journal=Journal of Psychosomatic Research|volume=42|issue=4|pages=369–378|issn=0022-3999|pmid=9160276}}</ref>. One example of this is the [[Tampa scale for kinesiophobia]], adapted for [[chronic fatigue syndrome]]. Some of the questions in this scale ask about the experience of PEM such as: "If I were to try to overcome it, my symptoms would increase" or "my symptoms let me know when to stop exercising so that I do not harm myself". Yet these symptoms are classified as an indicator of [[illness beliefs|irrational fear of movement and exercise]], instead of PEM.<ref>{{Cite web|url=http://www.paininmotion.be/EN/sem-TSK-CFSEnglish.pdf | title = Tampa Scale Kinesiophobia - Version Chronic Fatigue Syndrome | last = Nijs | first = J | last2 = De Meirleir | first2 = K | date = 2004 | website = painmotion.be|publisher=Archives of Physical Medicine and Rehabilitation|archive-url=|archive-date=|url-status=|access-date= | last3 = Duquet | first3 = W}}</ref>
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