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===Post-exertional malaise === [[Post-exertional malaise]] (PEM) is increasingly recognized as the hallmark symptom of ME/CFS, this means that patients suffer a [[relapse]] or [[crash]] when they exceed their limited [[energy limit]].<ref name="Vink2015" /><ref name="Vink2019">{{Cite journal | last = Vink | last2 = Vink-Niese | 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 | first2 = Alexandra|pmc=|pmid=|quote= | author-link = Mark Vink | authorlink2 = Alexandra Vink-Niese|via=}}</ref><ref name="NHS" /><ref name="CDC-symptoms" /> The [[Centers for Disease Control and Prevention|CDC]] states: <blockquote>"During PEM, any ME/CFS symptoms may get worse or first appear, including difficulty thinking, problems sleeping, sore throat, headaches, feeling dizzy, or severe tiredness. It may take days, weeks, or longer to recover from a crash. Sometimes patients may be house-bound or even completely bed-bound during crashes."<ref name="CDC-symptoms" /></blockquote> Dr [[Mark Vink]], a former marathon runner and international hockey player who now has severe ME states that walking the few steps from his bed to the toilet is only possible every 12 hours, due to the severe PEM it causes him.<ref name="marathon">{{Cite web|url=http://anilvanderzee.com/for-patients-with-cfs-going-to-the-bathroom-is-similar-to-running-a-marathon/ | title = For patients with CFS, going to the bathroom is similar to running a marathon. | last=de Visser | first=Ellen|authorlink=Ellen de Visser| date = 2017-10-03 | website = [[Anil van der Zee]]|language=en-GB|archive-url=|archive-date=|url-status=|access-date=2018-12-29}}</ref>
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