This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.
***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video five of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, review a study by Cook, et al., which investigated the relationship between a resting state and post-exercise induced PEM by evaluating performance upon several cognitive tasks, by imaging of the brain with functional MRI, and by patient-reported symptoms.

Video details:
- Paced Auditory Serial Task Addition (PASAT) cognitive task findings
- Post-exercise brain activity in the inferior and superior parietal and cingulate cortices
- Impact of PEM on neurophysiology

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Citations:
Cook DB, Light AR, Light KC, Broderick G, Shields MR, Dougherty RJ, Meyer JD, VanRiper S, Stegner AJ, Ellingson LD, Vernon SD. Neural consequences of post-exertion malaise in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Brain Behav Immun. 2017 May;62:87-99. doi: 10.1016/j.bbi.2017.02.009. Epub 2017 Feb 17. PMID: 28216087.

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.
***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video six of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, examine the physiological happenings within the brains of those with ME/CFS.

Video details:
- Microglial cells & proinflammatory cytokines (IL-6, TNF-alpha, and interleukin-1-beta)
- Magnetic resonance spectroscopy & metabolic activity associated with neuroinflammation
- Brain lactate & Choline
- Brain thermometry
- Positron emission tomography (PET): measuring radio-labeled isotope ligand to the translocator protein (or TSPO)
- Default Mode Network (DMN) uncoupling in ME/CFS

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Citations:
Torres-Platas, S.G., Comeau, S., Rachalski, A. et al. Morphometric characterization of microglial phenotypes in human cerebral cortex. J Neuroinflammation 11, 12 (2014). https://doi.org/10.1186/1742-2094-11-12

Mueller, C., Lin, J.C., Sheriff, S. et al. Evidence of widespread metabolite abnormalities in Myalgic encephalomyelitis/chronic fatigue syndrome: assessment with whole-brain magnetic resonance spectroscopy. Brain Imaging and Behavior 14, 562–572 (2020). https://doi.org/10.1007/s11682-018-0029-4

Nakatomi Y, Mizuno K, Ishii A, et al. Neuroinflammation in Patients with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis: An ¹¹C-(R)-PK11195 PET Study. J Nucl Med. 2014;55(6):945‐950. doi:10.2967/jnumed.113.131045

Rayhan RU, Baraniuk JN. Submaximal Exercise Provokes Increased Activation of the Anterior Default Mode Network During the Resting State as a Biomarker of Postexertional Malaise in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Neurosci. 2021;15:748426. Published 2021 Dec 15. doi:10.3389/fnins.2021.748426

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.
***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video seven of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, tie everything together, offering insights and guidance on clinical management of those who experience PEM/PESE.

It has been consistently observed that when patients finally break this cycle and avoid PEM for a more consistent period of time, their functional baseline and all aspects of their ME/CFS symptom control improve, independent of any other pharmacological or behavioral intervention.

Managing each and every pathological component of ME/CFS not only reduces the impact and suffering of those specific symptoms, but perhaps more importantly, can reduce the incidence, duration, and intensity of PEM and improve overall function and prognosis.

Video details:
- Pacing management/guidance
- Avoid the push/crash cycle ("stubbed toe analogy")
- Activity modification
- Trigger recognition/planning
- Budgeting rest breaks
- Low-dose naltrexone (LDN)

Note to community members: We advise viewers to always speak with their medical care team prior to making any adjustments or changes to their current regimen.

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.
***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video four of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, review studies showing how moderate exercise increases expression of sensory, adrenergic and immunologic genes in those with ME/CFS.

Video details:
- Sensory, adrenergic and immunological gene expression in those with ME/CFS, multiple sclerosis, and healthy controls at varying intervals pre/post exercise challenge.
- Reported symptom and gene expression comparison.

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Citations:
Light AR, White AT, Hughen RW, Light KC. Moderate exercise increases expression for sensory, adrenergic, and immune genes in chronic fatigue syndrome patients but not in normal subjects. J Pain. 2009 Oct;10(10):1099-112. doi: 10.1016/j.jpain.2009.06.003. Epub 2009 Jul 31. PMID: 19647494; PMCID: PMC2757484.

Light AR, Bateman L, Jo D, Hughen RW, Vanhaitsma TA, White AT, Light KC. Gene expression alterations at baseline and following moderate exercise in patients with Chronic Fatigue Syndrome and Fibromyalgia Syndrome. J Intern Med. 2012 Jan;271(1):64-81. doi: 10.1111/j.1365-2796.2011.02405.x. Epub 2011 Jul 13. PMID: 21615807; PMCID: PMC3175315.

Jacob D. Meyer, Alan R. Light, Sanjay K. Shukla, Derek Clevidence, Steven Yale, Aaron J. Stegner & Dane B. Cook (2013) Post-exertion malaise in chronic fatigue syndrome: symptoms and gene expression, Fatigue: Biomedicine, Health & Behavior, 1:4, 190-209, DOI: 10.1080/21641846.2013.838444

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.
***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video three of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, discuss how Serial 2-Day Cardiopulmonary Exercise Testing (CPET) is a reliable, reproducible and accurate measure of PEM/PESE among those with ME/CFS.

Video details:
- Peak VO2
- Ventilatory Anaerobic Threshold (VAT)
- Impact on ATP production/utilization
- Objective measurements supporting eligibility for disability benefits.

**NOTE: Healthcare providers must weigh the benefits of CPET testing against its potential harms, which could include the induction of a prolonged worsening on an individual’s ME/CFS as a result of the provocation of an extended episode of PEM.**

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Video citations:
J. Mark Vanness, Christopher R. Snell & Staci R. Stevens (2007) Diminished Cardiopulmonary Capacity During Post-Exertional Malaise, Journal of Chronic Fatigue Syndrome, 14:2, 77-85, DOI: 10.1300/J092v14n02_07

Stevens S, Snell C, Stevens J, Keller B, VanNess JM. Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Pediatr. 2018;6:242. Published 2018 Sep 4. doi:10.3389/fped.2018.00242

***
Learn more about CPET testing: Workwell Foundation https://workwellfoundation.org/

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.

***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video two of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD, review a cross-sectional study conducted by Dr. Lily Chu, et.al, outlining triggers, time to onset, symptoms and duration of PEM episodes. The phenomenon of variable intensity and frequency triggers for PEM has often been likened to an analogy of debt. Dr. Yellman concludes the video detailing how individuals with PEM/PESE can easily slip into this "energy debt" or "crash cycle," which demands ample and adequate rest and physiologic supports in an effort to return to baseline.

***
This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Video citations:
Chu L, Valencia IJ, Garvert DW, Montoya JG. Deconstructing post-exertional malaise in myalgic encephalomyelitis/ chronic fatigue syndrome: A patient-centered, cross-sectional survey. PLoS One. 2018;13(6):e0197811. Published 2018 Jun 1. doi:10.1371/journal.pone.0197811

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This video series is intended to review the clinical presentation, scientific underpinnings, and treatment approach for patients with post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE).

For an abbreviated version highlighting the clinical pearls, please watch videos 1, 2, and 7. Videos 3-6 offer a deeper dive into the scientific and evidence-based pathophysiology of PEM/PESE.

***
Post-exertional malaise (PEM)/post-exertional symptom exacerbation (PESE) is an altered physiological state and pathognomonic finding unique to ME/CFS that is now being recognized in those with post-acute sequelae of COVID-19 (PASC), also known as Long COVID.

It is critical that healthcare professionals recognize PEM/PESE and support the patient in avoiding a push-crash-cycle which can exacerbate disease processes and contribute to worsened long-term functional prognoses.

In video one of this seven-part series Brayden Yellman, MD, and Lucinda Bateman, MD introduce the:
- Definition of PEM/PESE
- Signs/symptoms
-Duration/intensity/severity of PEM/PESE
-PEM/PESE triggers

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

Citations:
Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press. (2015).

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The purpose of this video is to shine a light and bring awareness to the often unseen and debilitating nature of ME/CFS, fibromyalgia, Long COVID, and their co-existing conditions.

Background: We asked the lived-experience community and BHC staff to share reflections of their disease experience in the form of a picture, art, or poem. The poems can be found on the BHC blog.

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Patients who have post-exertional malaise (PEM/PESE) generally benefit more from pacing and energy conservation than exercise-focused treatments. Pacing for PEM/PESE involves managing exertion to stay under the threshold that causes increased symptoms or post-exertional malaise. While pacing is not a cure for PEM/PESE, it is an effective management strategy. Pacing and energy conservation approaches need to be individualized for each patient.

This video covers how therapy providers can use biofeedback pacing, task analysis, activity logs, and heart rate variability tracking to assist patients with pacing to reduce their symptoms.

Note to community members: We advise viewers to always speak with their medical care team prior to making any adjustments or changes to their current regimen.

This video was made possible by the OMF-funded Medical Education Resource Center (MERC) at BHC, our generous donors, and viewers like you.

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