Understanding Pacing - a key strategy for managing PEM in ME/CFS and Long Covid
- Isabel Hemmings
- May 12
- 5 min read
Updated: May 15
One of the most challenging aspects of living with ME/CFS or Long Covid is Post-Exertional Malaise (PEM)—a worsening of symptoms following physical, cognitive, or emotional exertion.
Effective management of PEM is crucial, and one of the most evidence-informed approaches is pacing. This blog explains what pacing is, why it matters, and how it can be used to support people living with ME/CFS or Long Covid.
What Is Post-Exertional Malaise (PEM)?
PEM is not simply “feeling tired after activity.” It is a hallmark symptom of ME/CFS characterised by a delayed and disproportionate worsening of symptoms—often 12 to 48 hours after exertion—and it can last days or weeks. Symptoms may include:
Severe fatigue
Cognitive dysfunction (“brain fog”)
Muscle pain
Flu-like symptoms
Sleep disturbances
Because PEM is unpredictable and can be triggered by minimal activity, it presents a major barrier to daily functioning.
The importance of addressing PEM
Research from Norway (Wormgoor, 2023) found that a lack of focus on PEM in hospital interventions and rehabilitation led to a significantly higher probability of health deterioration in patients
However, the study also found that when health professionals tailored their care around PEM, patient satisfaction, outcomes, and overall quality of life improved significantly. Addressing PEM can:
Prevent long-term deterioration
Reduce symptom severity
Improve day-to-day function
What Is Pacing?
Pacing is a self-management strategy designed to avoid triggering PEM by aligning activity levels with the body's available energy. The goal is to stay within one’s “energy envelope” to minimise crashes and promote stability.
It differs from graded exercise therapy (GET) in that pacing does not push beyond symptom limits and is not focused on gradually increasing activity through exertion.
Key features of pacing
Pacing is a self-management technique that helps individuals with ME/CFS or Long Covid manage their energy levels and prevent post-exertional malaise. It involves balancing activity and rest and learning to communicate these needs to others
Pacing involves setting boundaries and learning to say ‘no’ to activities that are beyond one's current capacity. This can be challenging, especially with family and work commitments. However, it is essential for managing ME effectively and preventing setbacks.
Pacing should not be seen as a cure for ME, but rather as a way of managing symptoms and improving quality of life. It is a personalised approach that requires trial and error to find what works best for each individual.
Increasing activity levels ("pacing up") should be done gradually and only after establishing a sustainable baseline. Know your limits and be prepared to step back if necessary.
Effective communication is a crucial aspect of self-management. People with ME may need to explain their condition and their pacing strategies to others, particularly in the context of work and family relationships. Assertiveness can be helpful in setting boundaries and communicating needs clearly.
Three Core Components of Pacing
Activity Analysis
Start by identifying which physical, cognitive, or emotional activities consume the most energy. Consider tracking:
Walking, chores, conversations
Reading, decision-making, screen time
Emotional stressors (e.g., socialising, worrying)
You can label activities as low, medium, or high energy, then plan your day to alternate or limit higher-demand tasks.
Establishing a Baseline
Your baseline is the amount of activity you can consistently do without triggering PEM. To find it:
Track activities and symptoms for 1–2 weeks
Identify patterns or thresholds
Use the “50% rule” to begin conservatively
You may find tools like timers, Fitbits, or energy logs useful for pacing. Building up should be slow and always based on symptom stability.
To establish a sustainable baseline, look at the detail of what you do, and how long you do it for, using the principle of a stop rule, which are detailed below:
3. Planned Rest and Recovery
Scheduled, intentional rest periods are essential. These can include:
Quiet, screen-free time
Breathing exercises or mindfulness
“Radical rest” before known exertion (e.g., before appointments). See below for more information
Don’t wait until symptoms escalate—rest proactively!
Rest and Relaxation
Rest and relaxation is an essential part of a successful pacing programme and you need to build this into your day. The amount of rest needed varies from person to person. Some people need a lot of rest while others find that, if they are getting good-quality rest, they can cope with short, frequent mini-rests, lasting as little as five to 10 minutes.
Radical rest
Radical rest is about pre-planning when you know there is a planned exertion coming e.g. attending a party, giving a talk etc It involves being inactive for a period of time before the planned event. The aim is to mitigate the effects of PEM.
Radical rest also involves preparing things in advance of the event, e.g.
• Pre-making meals
• Having water or snacks available
• Making sure medication is in reach
• Planning low-energy activities or rest days after the event
• Ask family/friends for additional help
The Role of Nutrition
Although pacing focuses on energy expenditure, fuelling the body well is equally important.
While there’s no universal “ME/CFS diet,” many find benefit from:
Anti-inflammatory foods (e.g., berries, leafy greens)
Omega-3-rich options (e.g., oily fish)
Protein/amino-acids - a lack of protein may reduce muscle mass. It may also reduce metabolic health, leading to inflammation. Protein rich foods include meat, offal, eggs, dairy, fish, soy, legumes
Balanced meals with protein, healthy fats, and slow carbs
Hydration and electrolyte management
Easy-prep ideas for low-energy days:
Mackerel pâté on toast
Boiled eggs and avocado
Yogurt with berries and seeds
Patient Insights
Here are some tips from people living with ME/CFS:
“Using a timer helps me avoid overdoing it, even when I feel good.”
“I’ve learned to say no to protect my health—it’s hard but necessary.”
“Pacing gave me some control back. It’s not about doing more, it’s about doing what I can safely.”
Conclusion
Pacing is a cornerstone of PEM management for people with ME/CFS. It requires patience, self-awareness, and consistency—but the benefits can be life-changing. Healthcare professionals, caregivers, and patients themselves can all support this approach by recognising its value and helping to embed it into daily routines.
Useful resources:
Pacing and management guide, ME Action:
Pacing for people with ME, Action for ME:
ME/CFS Post Exertional Malaise Avoidance Toolkit,
Explaining ME/CFS to other people leaflet
An Employer’s guide to ME/CFS
Supporting people with ME/CFS in hospital – advocating for reasonable adjustments
References
Wormgoor, Marjan, E, A, and Rodenberg, Sanne C, Focus on post-exertional malaise when approaching ME/CFS in specialist healthcare improves satisfaction and reduces deterioration. Front. Neurol., Dec 2023, Sec Neurorehabilitation, Vol 14 -2023. https://doi.org/10.3389/fneur.2023.1247698
Comments