Medscape: Post-Exertional Malaise in Fatiguing Diseases: What to Know to Avoid Harmful Exercise - by Miriam Tucker

[Kalliope]

Quote:

Identifying the phenomenon of post-exertional malaise (PEM) in patients with fatiguing conditions is critical because it necessitates a far more cautious approach to exercise, experts said.

PEM is a defining feature of the condition myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and it is present in many people with long COVID. It is characterized by a worsening of fatigue and of other symptoms after previously tolerated physical or mental exertion, typically emerging 24-72 hours after the exertion and lasting days or weeks thereafter. The experience is often called a “crash.”

In a study presented at American College of Rheumatology (ACR) 2024 Annual Meeting, PEM was also identified in people with various rheumatologic conditions, ranging from 4% in those with osteoarthritis to 20% in those with fibromyalgia. The presence of PEM was also associated with worse pain, sleep, cognition, and other symptoms that are also characteristic of ME/CFS and many cases of long COVID.


https://www.medscape.com/viewarticl...tiguing-diseases-what-know-avoid-2024a1000ot1

 

[Creekside]

PEM was also identified in people with various rheumatologic conditions

If true, that would be interesting, possibly showing that PEM was due to immune system activation.

 

[Nightsong]

In a study presented at American College of Rheumatology (ACR) 2024 Annual Meeting, PEM was also identified in people with various rheumatologic conditions, ranging from 4% in those with osteoarthritis to 20% in those with fibromyalgia. The presence of PEM was also associated with worse pain, sleep, cognition, and other symptoms that are also characteristic of ME/CFS and many cases of long COVID.

The study referred to is "Prevalence of Post-exertional Malaise (PEM) in Adults with Rheumatic Diseases and Relationship with COVID19 Infection" (Arthritis Rheumatol. 2024; 76 suppl 9) and used the PEM sub-scale questions from the DSQ:

https://acrabstracts.org/abstract/p...ases-and-relationship-with-covid19-infection/

Background/Purpose: Chronic fatigue is the dominant symptom in patients with Long COVID and Myalgic encephalomyelitis/Chronic fatigue syndrome (ME/CFS) as well as an important and prevalent symptom among patients with rheumatic diseases. Understanding the nature and interrelationship of the fatigue among these disorders is important both for epidemiologic understanding and clinical management. A cardinal and putative distinguishing feature of the fatigue present in patients with Long COVID and ME/CFS from other fatiguing states is the presence of post-exertional malaise (PEM) which refers to a worsening of fatigue and other fatigue related symptoms after exertion which was previously tolerated and often delayed 24-72 hours or more1. PEM has not been systematically investigated in rheumatic diseases and insights into its prevalence is an important initial step in further defining its nature and relationships of fatigue in these conditions compared to Long COVID and ME/CFS. The current study utilizing a validated instrument2 for the detection of PEM represents the first effort to define its prevalence across rheumatic diseases states and its relationship to COVID19 infection status.

Methods: Adult participants in the Forward Databank with rheumatic diseases completed comprehensive questionnaires including the PEM subscale questions from the DePaul Symptom Questionnaire from January through June 2024. PEM+ was defined as having at least a frequency ≥2 and simultaneously a severity ≥2 in any item on the survey. We categorized diagnoses into RA, OA, FMS, and SLE, and additionally those who met the 2016 Fibromyalgia criteria (FMS16) independent of primary diagnoses. Additional items included details of COVID19 infection, Long COVID diagnosis, and comorbidities.

Results: A total of 1158 participants completed the PEM questionnaire with 7.5% PEM+ (4.4% OA to 14% FMS, Table 1). The highest prevalence of 20% was associated with those meeting FMS16. While any prior COVID19 infection was associated with PEM+, more recent and hospitalized COVID19, and Long COVID diagnoses had higher PEM+. Table 2 shows association with PEM+ with worse health and disease symptoms including depression and widespread pain. In contrast, younger age was associated with PEM+. In addition, we present the breakdown of PEM items selected for those PEM+ in Table 3.

Conclusion: This is the first study we are aware of that presents PEM rates in a RMD population. We found important associations with PEM status including disease activity and COVID19 infection exposure that require additional understanding notably around the use of graded exercise.

 

[Yann04]

I almost feel we need to distinguish between two bits of PEM.

PESE which is the worsening or triggering of symptoms, I wouldn’t be surprised if this also happens in various other diseases.

PEBD? (post exertional baseline deterioration)? which is that “crash” where you have limited capacity do things you could outside of a crash, importantly the amount of exertion that induces more PEM is lowered. So basically induced functional disability from exertion. This is where that spiral of continuing to overexert while you are in a crash can lead to sort of “recursive” crashes which seem to be a common experience of how someone with the illness significantly deteriorates in severity. I doubt this is present in any other illnesses.

 

[Andy]

Putting aside the issues with DSQ for a moment, another explanation could be that those people who indicate PEM might actually have ME/CFS, whether through a mis-diagnosis or as a comorbidity.

 

[Jonathan Edwards]

Putting aside the issues with DSQ for a moment, another explanation could be that those people who indicate PEM might actually have ME/CFS, whether through a mis-diagnosis or as a comorbidity.

Indeed. 'Osteoarthritis' is pretty much a joke diagnosis anyway. Everyone over 60 qualifies for it. Fibromyalgia is understood to have major overlap with ME/CFS. RA includes a post-exertional symptom exacerbation that bears no relation to that in ME/CFS. And so on.

 

[Sly Saint]

Changed
Mon, 12/23/2024 - 11:07

https://medauth2.mdedge.com/content...ing-diseases-what-know-avoid-harmful-exercise

 

[Ash]

Indeed. 'Osteoarthritis' is pretty much a joke diagnosis anyway. Everyone over 60 qualifies for it. Fibromyalgia is understood to have major overlap with ME/CFS. RA includes a post-exertional symptom exacerbation that bears no relation to that in ME/CFS. And so on.

What is the post-exertional symptom exacerbation that is included in RA that is not like ME?

 

[Jonathan Edwards]

What is the post-exertional symptom exacerbation that is included in RA that is not like ME?

If you do a lot on day one then you are likely to wake up very stiff in the used joints on day two. It is a specific problem of rebound joint lining oedema as an exacerbation of chronic inflammatory infiltration. It takes about 12 hours, and a periodic of inactivity, to become manifest.

What I think that demonstrates is that simplistic descriptions of things like PEM or PESE are nothing like adequate to pick out symptom patterns that need to be recognised to make sensible medical decisions. Everything has to be seen in a huge context of related factors.

Lists of symptoms and questionnaires are never going to pick out diagnoses.

 

[Ash]

If you do a lot on day one then you are likely to wake up very stiff in the used joints on day two. It is a specific problem of rebound joint lining oedema as an exacerbation of chronic inflammatory infiltration. It takes about 12 hours, and a periodic of inactivity, to become manifest.

What I think that demonstrates is that simplistic descriptions of things like PEM or PESE are nothing like adequate to pick out symptom patterns that need to be recognised to make sensible medical decisions. Everything has to be seen in a huge context of related factors.

Lists of symptoms and questionnaires are never going to pick out diagnoses.

Ahh thank you. Yeah.

 

[Medfeb]

Indeed. 'Osteoarthritis' is pretty much a joke diagnosis anyway. Everyone over 60 qualifies for it. Fibromyalgia is understood to have major overlap with ME/CFS. RA includes a post-exertional symptom exacerbation that bears no relation to that in ME/CFS. And so on.

@Jonathan Edwards - could you expand on this comment? In what way is the post-exertional symptom exacerbation in RA different from that in ME/CFS? I'm trying to understand how doctors might differentiate the two