Pacing is a strategy used to avoid post-exertional malaise (PEM). All patients with ME/CFS suffer from some form of PEM. Patients who are mildly ill may only feel an increase in fatigue, while patients who have more severe form of the illness can suffer an exacerbation of all their symptoms, including swollen glands, flu-like symptoms, pain, insomnia, and a general “crash.”
According to Dr. Myhill, the reason patients with ME/CFS have such a marked response to exertion, whether its physical or mental, is that supplies of ATP, the molecule that supplies cellular energy, do not regenerate quickly enough after they are used. As a consequence, every cellular function is disrupted.
Staying within the “energy envelope,” or pacing, is one way a person with ME/CFS can help mitigate PEM. Avoiding activities which will place too great a strain on the body’s ability to produce adequate ATP is a key strategy of pacing, but adequate rest is equally as important. What is important in pacing is to avoid crossing the energy threshold.
Knowing when you have crossed the energy threshold is tricky. In part, it depends on how ill a person is. A severely ill patient crosses the energy threshold daily simply by being ill. However, mildly and moderately ill patients may not even be aware when they have “done too much.” For these patients, it is important to adjust activities to avoid the worst effects of PEM.
These are some important strategies to help patients pace:
- Rest between activities. No matter what you are doing, don’t do it continuously. Take frequent breaks.
- Stop before you feel like stopping. Often people with ME/CFS don’t know they have over-exerted themselves until it is too late.
- Don’t do anything that makes your heart pound. Avoid walking up stairs, running(!), standing too long if you have orthostatic intolerance, or doing any other activity that will increase your heart rate.
- Don’t push. Healthy people can push past weariness without any major long-term effects. But “no pain, no gain” can cause a permanent set-back in patients with ME/CFS.
- Always do less than you think you can do. People with ME/CFS almost universally think they can do more than they can. This is because they remember what they were able to do before they were ill. Making the adjustment to doing less, often much less, can be difficult. However, it is crucial.
- “Don’t stand if you can sit, and don’t sit if you can lie down.” This advice was given by Dr. Richard Bruno to his post-polio patients. It applies equally as well to people with ME/CFS.
- Know your limits. This strategy may be hard to implement in a disease that changes daily, if not hourly. But there are certain activities that most patients come to realize will push them over the edge.
- Plan ahead. Patients who are moderately ill can shop for themselves, take care of household tasks, and attend to their own needs. For these patients, planning ahead is a necessity. Don’t do more than one task a day! For example, if you have a doctor’s appointment, don’t also go shopping. If you need to attend a family event, find a time during the event to rest, retreat, or lie down.
More information
Continued and repeated episodes of PEM/PESE are associated with worsened long-term functional capacity for individuals with ME/CFS and Long COVID. The Push Crash Cycle handout shows providers the types of exertion that can lead to PEM/PESE.
Bateman Horne Center’s two-page guide to pacing.
Pacing for ME/CFS: The Facts
Dr. Ellen Goudsmit discusses how pacing developed as an accepted form of management for ME/CFS and explains why it works.
Pacing by Numbers: Using Your Heart Rate To Stay Inside the Energy Envelope.
Bruce Campbell suggests monitoring your heart rate to stay below your anaerobic threshold.
“Diagnosing and Treating Chronic Fatigue Syndrome”
Dr. Myhill’s book (available for free online) contains a number of helpful suggestions for pacing yourself.
The Spoon Theory Gave People the Wrong Idea About My Illness
This excellent article by Jennie Smales explains some of the pitfalls of managing an illness that is unpredictable.
Workwell’s Factsheet on Activity Management with a Heart Rate Monitor
Heart rate monitoring provides real-time biofeedback that promotes symptom awareness and control. When heart rate is associated with symptoms and perceived exertion, it can be a powerful tool to manage
post-exertional malaise (PEM), i.e., worsening symptoms after activity.
Solve M.E. Patient and Caregiver Resource Guide: Post Exertional Malaise (PEM) and Rest
As a person with ME/CFS, you need to determine your individual limits for physical and mental activity, and plan your day accordingly. Through trial and error and tracking your symptoms after differing types of activities, you can find your rhythm to avoid “crashes.” Rest is the main ingredient for reinstating your physical equilibrium.
ME/CFS South Australia’s Worksheet on Pacing
Describes different types of pacing and how to avoid PEM. “Living within available energy reserves will reduce the incidence of PEM, leading to a more stable daily life. Over time, consistent pacing may lead to an improvement in the baseline level of symptoms and an ability to do more.”
The ME/CFS Pacing App allows you to log your daily activities and use its personalised “energy currency” system to better manage your daily energy. You decide how much each activity is worth within this currency to you. For example, reading a book takes a different amount of energy for each person and you chose how many points from your “energy currency” to give each activity. This allows the user to see visually where in the day they used too much energy and what days were well balanced.
Better Living Through Technology: Devices as Aids to Pacing
One of the biggest challenges in ME/CFS and fibro is learning to stay within the limits imposed by illness. Your effort to stay inside your energy envelope can be aided by the use of devices of various kinds, such as those described here.
Bruce Campbell offers an introduction to pacing via three success stories.
Pacing and Management Guide for ME/CFS and Long COVID
The updated version of this useful guide contains concise descriptions of the illnesses and their symptoms, and provides guidance for pacing to help prevent post-extertional malaise (PEM). Citations to the relevant literature and other resources are listed.