Post-exertional malaise (PEM) is one of the most frustrating and debilitating aspects of long COVID and ME/CFS. But if you’ve only just heard of PEM, you might recognise it as that overwhelming fatigue, brain fog, or flu-like crash that happens after doing what used to be normal activities. Many people with long COVID or chronic fatigue symptoms experience PEM without realising what it is.
If you’re new to PEM, seasoned long haulers have learned—often the hard way—how to manage it better.
1. Learn to Pace (Seriously, This is Non-Negotiable!)
PEM happens when you exceed your body’s current energy limits. Pacing is the practice of breaking up activities to avoid pushing beyond your energy “envelope.”
- Use the “Stop, Rest, Pace” method: Stop before you feel exhausted, rest often, and plan your activities carefully.
- Track your energy levels daily to recognise patterns and avoid crashes.
2. Forget “Pushing Through” – It Doesn’t Work
Many of us were taught that if we push through fatigue, we’ll get stronger. PEM doesn’t work like that. Overexertion only leads to crashes that can last days or weeks.
- Respect your body’s limits, even if it means stopping an activity earlier than you’d like.
- Remind yourself: “Rest now or pay later.”
3. Listen to Your Heart (Literally)
Your heart rate can be a useful guide to prevent PEM.
- Consider wearing a heart rate monitor to stay within your safe zone.
- Some long haulers use the 50-60% rule of their max heart rate to prevent overexertion.
4. Plan, Prioritise, and Cut Corners Where You Can
You only have so much energy each day. Prioritise essential tasks and simplify where possible.
- Online grocery shopping? Yes.
- Taking shortcuts like prepping meals in advance? Absolutely.
- Saying no when needed? A lifesaver.
5. Rest Before You Need To
Resting only after you feel exhausted is too late. Preemptive rest helps prevent PEM crashes.
- Schedule regular rest breaks, even on “good” days.
- Think of rest as an investment in future energy, not as a sign of weakness.
6. Accept That Every Day is Different
PEM is unpredictable. One day, a short walk might be fine; the next, it might trigger a crash.
- Have backup plans for days when you can’t function as planned.
- Don’t beat yourself up if you need to rest more than expected.
7. Find Tools That Help Reduce Effort
Small adjustments can save a lot of energy.
- Mobility aids, shower stools, meal delivery services, and voice-to-text apps are not giving up—they’re smart energy conservation tools.
- Think about what daily tasks drain you the most and find ways to make them easier.
8. Manage Sensory Overload
Loud noises, bright lights, and crowded spaces can all contribute to PEM.
- Noise-cancelling headphones, sunglasses, and quiet spaces can be lifesavers.
- Reduce unnecessary stimuli when you need to conserve energy.
9. Know Your Warning Signs
PEM doesn’t always hit immediately—it can take hours or even a day to show up.
- Watch for early signs like brain fog, increased heart rate, dizziness, or heavy limbs.
- When in doubt, rest first—it’s easier to prevent a crash than recover from one.
10. Be Kind to Yourself
PEM can be frustrating, but beating yourself up won’t help.
- Recognise that managing PEM is an ongoing learning process.
- Celebrate small wins, like successfully pacing or preventing a crash.
- Connect with others who understand—support groups can be a source of encouragement and advice.
11. Find Your Community and Be Your Own Advocate
Many doctors are still unfamiliar with PEM and may not fully understand how it impacts daily life. Advocating for yourself is crucial.
- Join online support groups—other long haulers can offer valuable insights and strategies that even medical professionals may not know.
- Educate your doctors—bring research, explain PEM clearly, and don’t be afraid to push for better care.
- Trust your experience—you know your body better than anyone else, and learning to advocate for your needs can make all the difference.
12. Exercise and the Energy Envelope: A Balanced Approach
Exercise can be beneficial for many conditions, but for those with PEM, it must be approached with extreme caution.
- Graded exercise therapy (GET) is not recommended for PEM, as pushing through can worsen symptoms.
- Some people find gentle stretching or very light movement helpful, but only if it does not trigger PEM.
- Always stay within your energy envelope—if an activity worsens symptoms later, it was too much.
- Focus on functional movement rather than fitness goals—conserving energy for daily tasks is often more important than structured exercise.
Final Thoughts
Managing PEM is a skill that takes time to develop. Long haulers have learned through experience that pacing, planning, and self-compassion are key to living with PEM. While it’s not always possible to avoid crashes completely, these tips can help you reduce their frequency and severity.
If you’ve been experiencing unexplained fatigue, brain fog, dizziness, or exhaustion that gets worse after activity, you may be dealing with PEM. Recognising it is the first step toward better management.
You’re not alone in this—learning to live with PEM is challenging, but with the right strategies, you can improve your quality of life.
Disclaimer: This article is for informational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns.
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