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[[File:Boom-and-bust-activity-cycle-animated.gif|thumb|right|After energy limits are exceeded, a dramatic increase in symptoms follows that prevents the patient from doing even minimal activity.]] Many ME/CFS patients attempt to '''"push through" symptoms''' by ignoring them and trying to do their usual activities when they first become ill with [[myalgic encephalomyelitis|ME]]/[[chronic fatigue syndrome|CFS]]<ref name="Vink2019" /><ref name="Vink2021a" /> - but people with ME/CFS find that exceeding their available energy - their [[energy envelope|"energy envelope"]] - causes [[post-exertional malaise]], making their health much worse.<ref name="Vink2021a" /><ref name="CDC-symptoms" /> This post-exertional malaise or post-exertional symptom exacerbation is a mandatory symptom of ME/CFS but is not usually found in other illnesses that can cause [[chronic fatigue]].<ref name="ICC2011primer"/><ref name="CDC-symptoms"/> ==Effects == If a person with ME/CFS ''does'' manage to push through their symptoms and exceeds their "[[energy limit]]," the result is a [[delayed onset of post-exertional symptoms]], better known as [[post-exertional malaise]], which can begin be delayed from between 24 hours to 3 days after over-exerting - the [[Recovery period is prolonged, usually taking 24 hours or longer|prolonged recovery time]] is usually over 24 hours, making it impossible for patients to consistently push through their symptoms without a significant, and longer, [[crash]].<ref name="canadianconsensus-CCC"/> {{Quote|quote=Saunders (2020) states that anyone whose symptoms are not made worse by "pushing through" [[fatigue]] and other symptoms by definition does not have ME/CFS.<ref name="Vink2021a">{{Cite journal| title = The draft updated NICE guidance for ME/CFS highlights the unreliability of subjective outcome measures in non-blinded trials | date = 2021-01-28|url=https://journals.sagepub.com/doi/abs/10.1177/1359105321990810|journal=Journal of Health Psychology|volume=27|issue=1 | pages = 9–12 | last = Vink | first = Mark | authorlink = Mark Vink | last2 = Vink-Niese | first2 = Alexandra | authorlink2 = |doi=10.1177/1359105321990810|pmc=|pmid=|access-date=|issn=1359-1053|quote=|via=}}</ref>}} ==Boom and bust == When they become worse after pushing through their symptoms, people with ME/CFS then have to choose again between [[rest]] or trying again to "push through" - which causes them to deteriorate further, until eventually they physically cannot continue. Both resting and pushing through result in an "[[greatly lowered ability to do activities that were usual before the illness]]", a symptom that is required for the diagnosis of ME/CFS.<ref name="CDC-symptoms">{{Cite web|url = https://www.cdc.gov/me-cfs/symptoms-diagnosis/symptoms.html| title = Symptoms {{!}} Myalgic Encephalomyelitis/Chronic Fatigue Syndrome|website=[[Centers for Disease Control and Prevention]] | date = Jan 27, 2021|access-date=2021-02-25}}</ref><ref name="niceng206">{{Cite web|url=https://www.nice.org.uk/guidance/ng206| title = Myalgic Encephalomyelitis (or Encephalopathy)/Chronic Fatigue Syndrome:diagnosis and management. NICE guideline. | last=NICE Guideline Development Group | first = | authorlink = |publisher=[[National Institute for Health and Care Excellence]] | date = 2021-10-29}}</ref> The cycle of repeatedly exceeding energy limits by doing too much activity followed by being forced to totally stop has been referred to as the "[[Boom and bust activity cycle|boom and bust cycle]]", and is very widely recognized in ME/CFS, and in some patients without post-exertional malaise, including [[chronic pain]] and [[chronic fatigue]] patients.<ref name="Antcliff2021">{{Cite journal| title = “Pacing does help you get your life back”: The acceptability of a newly developed activity pacing framework for chronic pain/fatigue|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/msc.1557|journal=Musculoskeletal Care|volume=n/a|issue=n/a | last = Antcliff | first = Deborah | last2 = Keenan | first2 = Anne-Maree | last3 = Keeley | first3 = Philip | last4 = Woby | first4 = Steve | last5 = McGowan | first5 = Linda|language=en|doi=10.1002/msc.1557|issn=1557-0681}}</ref> A significant proportion of people with [[Long COVID]] report experiencing post-exertional malaise and find they have a boom and bust cycle as a result.<ref name="Horton2010">{{Cite journal| title = Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adults: a qualitative study of perspectives from professional practice | date = 2010-11-15|url=https://doi.org/10.1186/1471-2296-11-89|journal=BMC Family Practice|volume=11|issue=1 | pages = 89 | last = Horton | first = Simon MC | authorlink = | last2 = Poland | first2 = Fiona | authorlink2 = | last3 = Kale | first3 = Swati | author-link3 = | last4 = de Lourdes Drachler | first4 = Maria | authorlink4 = | last5 = de Carvalho Leite | first5 = Jose Carlos | authorlink5 = | last6 = McArthur | first6 = Maggie A. | authorlink6 = | last7 = Campion | first7 = Peter D. | last8 = Pheby | first8 = Derek | authorlink8 = Derek Pheby | last9 = Nacul | first9 = Luis | authorlink9 = Luis Nacul|doi=10.1186/1471-2296-11-89|pmc=PMC2994803|pmid=21078171|access-date=|issn=1471-2296|quote=|via=}}</ref> {{See also|Boom and bust activity cycle}} ==Pacing as an alternative == The main alternative to pushing through symptoms in ME/CFS is activity pacing. [[Pacing]] or "energy management" is a way of planning and monitoring activity to try to avoid exceeding energy limits, in order to avoid the resulting periods of [[post-exertional malaise]], which often involves patients being forced to spend days in bed recovering.<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><ref name="canadianconsensus-CCC">{{Cite journal | last1 = Carruthers | first1 = Bruce M. | authorlink1 = Bruce Carruthers | last2 = Jain | first2 = Anil Kumar | authorlink2 = Anil Kumar Jain | last3 = De Meirleir | first3 = Kenny L. | authorlink3 = Kenny De Meirleir | last4 = Peterson | first4 = Daniel L. | authorlink4 = Daniel Peterson | last5 = Klimas | first5 = Nancy G. | authorlink5 = Nancy Klimas | last6 = Lerner | first6 = A. Martin | authorlink6 = Martin Lerner | last7 = Bested | first7 = Alison C. | authorlink7 = Alison Bested | last8 = Flor-Henry | first8 = Pierre | authorlink8 = Pierre Flor-Henry | last9 = Joshi | first9 = Pradip | authorlink9 = Pradip Joshi | last10 = Powles | first10 = AC Peter | authorlink10 = A C Peter Powles | last11 = Sherkey | first11 = Jeffrey A. | authorlink11 = Jeffrey Sherkey | last12 = van de Sande | first12 = Marjorie I. | authorlink12 = Marjorie van de Sande | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols| journal = Journal of Chronic Fatigue Syndrome | volume = 11 | issue = 2 | pages = 7-115 | date = 2003 | pmid = | doi = 10.1300/J092v11n01_02| url = http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf}}</ref> {{See also|Pacing}} {{See also|Energy Envelope Theory}} ==Inability to push through == Some ME/CFS patients find themselves totally unable to push through their symptoms, the intensity of the symptoms becomes too severe, and this is not necessarily limited to [[severe and very severe ME|severe ME/CFS]] patients. Professor [[Malcolm Hooper]] describes British politician Brynmor John's experience of ME/CFS: "On 13th December 1988 Brynmor John MP died from [[ME/CFS]]. His experience of the illness was all too familiar: {{Quote|text=Though there is only a slight gradient from our house to the main road, it could have been the North face of the Eiger. I just could not get up it.|source=Magical Medicine: How to make a disease disappear (2010)}} "He found himself unable to dress; the slightest [[exertion]] exhausted him and it took days to regain his strength. He was irritated by the profusion of [[Biopsychosocial model|psychiatric comment]] and was trying to ensure better understanding of [[ME/CFS]] (Perspectives, Summer 1991:28‐30). Brynmor John suddenly collapsed and died as he was leaving the UK Parliament's House of Commons gym after having been advised to [[exercise]] back to fitness."<ref name=magicalmedicine>{{Citation | last = Hooper | first = Malcolm | authorlink = Malcolm Hooper | last2 = Williams | first2 = Margaret | authorlink2 = Margaret Williams| title = Magical Medicine: How to make a disease disappear | date = Spring 2010|url= http://www.investinme.org/Documents/Library/magical-medicine.pdf}}</ref><ref name="Price2012">{{Cite book |chapter=We are the ones we have been waiting for | first =Adam | last = Price |quote =The Pontypridd by-election, following the death from exhaustion of Brynmor John was held on 23 February that year. | title =25/25 Vision: Welsh Horizons Across 50 Years | pages =108-109 | url=https://www.iwa.wales/wp-content/media/2016/03/25-25-vision-midsize-optimized-1.pdf | date = Sep 2012 |publisher =Institute of Welsh Affairs | editor-first = John | editor-last = Osmond|editor-first2 = Peter |editor-last2=Finch}}</ref> ==CBT and GET== [[Cognitive behavioral therapy]] (CBT) and [[graded exercise therapy]] (GET) for ME/CFS both encourage people to push through symptoms. In CBT patients are encouraged to view the fact that ME/CFS is a serious, physical illness - as the Institute of Medicine (2015) states it is - as an "[[illness beliefs|illness belief]]" to be challenged rather than a scientific fact.<ref name="SEID-IOM2015" /><ref name="Strassheim2021" /> In CBT patients are expected to set "realistic" goals for what they would like to achieve and work towards those goals<ref name="Vink2020LC" /> - but with no biomarker or physical way to measure symptoms,<ref name="Geraghty2016" /><ref name="SEID-IOM2015">{{Cite book | last = Institute of Medicine | authorlink = Institute of Medicine| title = Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness|location=Washington, DC|publisher=The National Academies Press | date = 2015 | url=https://www.ncbi.nlm.nih.gov/books/NBK284902/ |isbn=0309316898 | pmid = 25695122 |doi = 10.17226/19012 }}</ref> patients are unaware of the severity of their illness - they may be working towards goals that are actually not simply unrealistic but impossible. Patients may be told that they have a maladaptive [[kinesiophobia|fear of or avoidance of exertion]] that is causing them to reduce their activities,<ref name="Geraghty2016" /> and causing reversible [[deconditioning]],<ref name="Geraghty2016" /> but scientific research shows that people cannot push through their symptoms on consecutive days - the [[post-exertional malaise]] caused by ME/CFS prevents this. Patients in the [[United Kingdom|UK]] completing CBT for ME/CFS based on this [[biopsychosocial model]] were found to remain "severely disabled".<ref name="Vink2021-CBT" /><br> In [[graded exercise therapy]] (GET) ME/CFS patients are expected to commit to very gradually increasing their activity levels, and are told to "push through" regardless of how much their symptoms worsen - they are told increases in symptoms are temporary but evidence shows this is a false assumption. A very large survey of UK patients found this GET approach caused most people to become more ill.<ref name="OxfordBrookesSurvey">{{Cite web|url = https://www.meassociation.org.uk/wp-content/uploads/NICE-Patient-Survey-Outcomes-CBT-and-GET-Final-Consolidated-Report-03.04.19.pdf| title = Evaluation of a survey exploring the experiences of adults and children with ME/CFS who have participated in CBT and GET interventional programmes. FINAL REPORT | last = Oxford Clinical Allied Technology and Trials Services Unit (OxCATTS) | date = Feb 27, 2019}}</ref> == Evidence == Trying to "push through" symptoms or "keep going" is a common response when people with [[ME/CFS]] feel pressured to continue working or continue their usual activities - but ME/CFS then causes symptoms to get far worse, this [[post-exertional symptom exacerbation]] and [[post-exertional malaise]] is the hallmark symptom of ME/CFS.<ref name="Strassheim2021" /><br> Patients with [[severe and very severe ME|severe ME]] - which means that they either almost fully housebound or may be bedbound - report being encouraged to "push through" or "keep going" - even after they became worse.<ref name="Strassheim2021" /> Patients who are working when they fall ill with ME/CFS find that pushing they causes longer sickness absences from work, and any recovery is slowed down.<ref name="Vink2019">{{Cite journal | date = 2019-09-20| title = Work Rehabilitation and Medical Retirement for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Patients. A Review and Appraisal of Diagnostic Strategies|url=https://www.mdpi.com/2075-4418/9/4/124|journal=Diagnostics|language=en|volume=9|issue=4|pages=124|doi=10.3390/diagnostics9040124|issn=2075-4418 | first = Mark | last = Vink | authorlink = Mark Vink | first2 = Alexandra | last2 = Vink-Niese | authorlink2 = |pmc=|pmid=|quote=|access-date=|via=}}</ref> {{Quote frame|People with ME/CFS often feel under pressure to continue working when they first become ill or when their symptoms worsen. Unfortunately, trying to push through this illness is counterproductive, potentially causing longer sickness absences and slower recovery.|source= Vink and Vink-Niese (2019)<ref name="Vink2019"/>}} "Even though she feels very unwell, she tries to ignore or “push through” her symptoms, to push them out of her consciousness, and to continue her regular activities. Eventually, however, Elizabeth’s exhaustion, increased [[myalgia|muscle pain]], and [[headache]]s make it impossible for her to ignore her symptoms; she has trouble climbing the few steps into her front door." In a survey asking over 1,100 people with ME/CFS or [[fibromyalgia]] what they wish they had dond differently, "listened to my body more / stopped pushing so much" was the most common response, chosen by 78% of the group, and "been more careful not to overdo when I had good moments" was the second most common response.<ref name="tips">{{cite web|url=https://www.healthrising.org/blog/2019/06/23/chronic-fatigue-fibromyalgia-doctor-treatment-coping-done-differently-survey/| title = The ME/CFS and Fibromyalgia “What Would You Have Done Differently” Survey | website = Health Rising | first = Cort | last= Johnson | authorlink = Cort Johnson | date = Jun 23, 2019}}</ref> ==Clinicians== Pushing through symptoms is strongly advised against by clinicians, regardless of which alternative treatments they recommend instead.<ref name="niceng206"/><ref name="ICC2011primer"/> ==Risks and safety== Pushing through ME/CFS symptoms is widely recognized as harmful, and in some cases leads to long-term or permanent increase in symptoms which do not resolve when the patient stops attempting to push through. Many patients report developing [[severe and very severe ME|severe ME/CFS]] after pushing through symptoms of [[Mild myalgic encephalomyelitis or chronic fatigue syndrome|mild]] or [[moderate myalgic encephalomyelitis or chronic fatigue syndrome|moderate ME/CFS]]. ==Costs and availability== Free and available to all. ==Notable studies == *2016, Cognitive behavioural therapy in the treatment of chronic fatigue syndrome: A narrative review on efficacy and informed consent<ref name="Geraghty2016">{{Cite journal | last = Geraghty | first = Keith J | author-link = Keith Geraghty | last2 = Blease | first2 = Charlotte | authorlink2 = Charlotte Blease | date = 2016-09-15| title = Cognitive behavioural therapy in the treatment of chronic fatigue syndrome: A narrative review on efficacy and informed consent|url=https://www.researchgate.net/profile/Keith_Geraghty/publication/308181085_Cognitive_behavioural_therapy_in_the_treatment_of_chronic_fatigue_syndrome_A_narrative_review_on_efficacy_and_informed_consent/links/5a15a37e4585153b546ca7c7/Cognitive-behavioural-therapy-in-the-treatment-of-chronic-fatigue-syndrome-A-narrative-review-on-efficacy-and-informed-consent.pdf|journal=Journal of Health Psychology|volume=23|issue=1|pages=127–138|doi=10.1177/1359105316667798|issn=1359-1053|via=}}</ref> - [https://www.researchgate.net/profile/Keith_Geraghty/publication/308181085_Cognitive_behavioural_therapy_in_the_treatment_of_chronic_fatigue_syndrome_A_narrative_review_on_efficacy_and_informed_consent/links/5a15a37e4585153b546ca7c7/Cognitive-behavioural-therapy-in-the-treatment-of-chronic-fatigue-syndrome-A-narrative-review-on-efficacy-and-informed-consent.pdf (Full text)] * 2019, [https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/ Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome]<ref name="Tack2019">{{Cite web|url=https://blogs.bmj.com/medical-humanities/2019/07/04/why-graded-exercise-therapy-and-cognitive-behaviour-therapy-are-controversial-in-chronic-fatigue-syndrome/| title = Why Graded Exercise Therapy and Cognitive Behaviour Therapy are Controversial in Chronic Fatigue Syndrome | last = Michiel | first = Tack | authorlink = Michiel Tack | date = Jul 4, 2019 | website = BMJ Medical Humanities Blog|language=en-US|archive-url=|archive-date=|access-date=2019-07-09}}</ref> *2020, Could Cognitive Behavioural Therapy Be an Effective Treatment for Long COVID and Post COVID-19 Fatigue Syndrome? Lessons from the Qure Study for Q-Fever Fatigue Syndrome<ref name="Vink2020LC">{{Cite journal| title = Could Cognitive Behavioural Therapy Be an Effective Treatment for Long COVID and Post COVID-19 Fatigue Syndrome? Lessons from the Qure Study for Q-Fever Fatigue Syndrome | date = 2020-12-11|url=https://www.mdpi.com/2227-9032/8/4/552|journal=Healthcare|volume=8|issue=4|pages=552 | last = Vink | first = Mark | authorlink = Mark Vink | last2 = Vink-Niese | first2 = Alexandra | authorlink2 = |language=en|doi=10.3390/healthcare8040552|pmc=PMC7764131|pmid=33322316|access-date=|issn=2227-9032|quote=|via=}}</ref> - [https://www.mdpi.com/2227-9032/8/4/552 (Full text)] *2021, Experiences of Living with Severe Chronic Fatigue Syndrome/Myalgic Encephalomyelitis<ref name="Strassheim2021">{{Cite journal| title = Experiences of Living with Severe Chronic Fatigue Syndrome/Myalgic Encephalomyelitis | date = 2021-02-05|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914910/|journal=Healthcare|volume=9|issue=2|pages=168 | last = Strassheim | first = Victoria | authorlink = Victoria Strassheim | last2 = Newton | first2 = Julia L. | authorlink2 = Julia Newton | last3 = Collins | first3 = Tracy | authorlink3 = |doi=10.3390/healthcare9020168|pmc=7914910|pmid=33562474|access-date=|issn=2227-9032|quote=|via=}}</ref> - [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914910/ (Full text)] *2021, Elements of Suffering in Myalgic Encephalomyelitis /Chronic Fatigue Syndrome: The Experience of Loss, Grief, Stigma, and Trauma in the Severely and Very Severely Affected<ref name="Fennell2021">{{Cite journal| title = Elements of Suffering in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: The Experience of Loss, Grief, Stigma, and Trauma in the Severely and Very Severely Affected | date = 2021-05-09|url=https://pubmed.ncbi.nlm.nih.gov/34065069/|journal=Healthcare (Basel, Switzerland)|volume=9|issue=5|pages=553 | last = Fennell | first = Patricia A. | author-link = Patricia Fennell | last2 = Dorr | first2 = Nancy | authorlink2 = | last3 = George | first3 = Shane S. | authorlink3 = |doi=10.3390/healthcare9050553|pmc=8150911|pmid=34065069|access-date=|issn=2227-9032|quote=|via=}}</ref> - [https://www.mdpi.com/1101812 (Full text)] *2021, CFS patients remain severely disabled after specialist treatment with CBT in the UK<ref name="Vink2021-CBT">{{Cite journal| title = CFS patients remain severely disabled after specialist treatment with CBT in the UK | date = 2021-05-27|url=https://dx.doi.org/10.1177/01410768211013447|journal=Journal of the Royal Society of Medicine|volume=114|issue=6|pages=284–284 | last = Vink | first = Mark | authorlink = Mark Vink | last2 = Vink-Niese | first2 = Alexandra | authorlink2 = |doi=10.1177/01410768211013447|pmc=PMC8212546|pmid=34042529|access-date=|issn=0141-0768|quote=|via=}}</ref> - [https://www.researchgate.net/profile/Mark-Vink-2/publication/351914009_CFS_patients_remain_severely_disabled_after_specialist_treatment_with_CBT_in_the_UK/links/60afa16c458515bfb0aaebdf/CFS-patients-remain-severely-disabled-after-specialist-treatment-with-CBT-in-the-UK.pdf (Full text)] ==See also == *[[Substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities|Lack of energy for daily living activities]] *[[Post-exertional malaise]] *[[Crash]] ==Learn more == *[https://www.healthrising.org/blog/2019/06/23/chronic-fatigue-fibromyalgia-doctor-treatment-coping-done-differently-survey/ The ME/CFS and Fibromyalgia “What Would You Have Done Differently” Survey] - Health Rising ==References == {{Reflist}} [[Category:Management strategies]]
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