Post-exertional malaise (PEM) or “payback” can be one of the most frustrating symptoms of chronic fatigue and chronic illness. PEM is a condition where there is a definitive worsening of symptoms after exercise or challenging the body in some way (this could be mentally, physically or emotionally).
The onset of PEM may vary from person to person. It can happen immediately after the exercise or challenge, it can gradually come on a few hours later or the next day. It can last a few hours or a few days depending on the person.
Often when someone experiences PEM they may feel that if they just “push through” the body will adjust. Most typically, if you are experiencing PEM, the exercise, activity or challenge was too much. It could have been too much for your body physically or too much for your nervous system.
Either way, PEM is feedback that we can embrace and use to learn what our bodies need and build our routines. However, this doesn’t mean that we want to experience PEM too often, or at all if we can help it. Therefore we want to understand what we can do to mitigate PEM as we navigate Chronic Fatigue.
Understanding Oxidative Stress
The concept of oxidative stress and how it relates to PEM is best understood using exercise as an example. Oxidation is what happens when metal rusts. Biochemically, it is what happens when one molecule loses an electron from one of the pairs on its outer shell. This makes the molecule unstable and this can set off a chain of reactions where one cell after another becomes damaged (creating instability on a cellular level).
Oxidation is continuously occurring in the body and in some cases, in the right dosage, it can be self-protective. For example, when a healthy person exercises, the exercise will produce a small amount of damage which increases the number and/or density of mitochondria in the cell and over time, the body can make more energy!
However, when someone with an energy limiting condition, like Chronic Fatigue, does the same amount of exercise, they produce a disproportional amount of oxidative stress. This causes excessive amounts of damage and inflammation in the body which may be responsible for “flu-like” feelings such as achy muscles, brain fog, heaviness and fatigue.
Simply put, when we exert ourselves outside of our capacity, this causes an inflammatory response which is too overwhelming for the body and we experience this as PEM or in extreme cases a full blown energy crash.
With this understanding in mind, here are 6 things that can help you reduce or avoid PEM.
1. Manage Your Workload
This may seem obvious but needs to be highlighted first and foremost. We must stay within our capacity as exceeding our capacity, whether that is physically, mentally or emotionally, will likely trigger some form of malaise.
If what you have chosen to do is too much for your body, then it is likely that your body may go into “threat” mode. While your body deals with the threat, energy is prioritised towards defence and away from energy production. You may experienced increased sympathetic activation (increased heart rate, anxiety, difficulty sleeping) and inflammatory symptoms associated with PEM due to an increased immune response.
Nobody wants to be told to do less,but unfortunately, this is exactly what you may need to do. If you are exercising, you’ll want to find the sweet spot at which you can move, without exacerbating your symptoms and over time, slowly condition your body to do more. If you aren’t at a stage yet where you can do formal exercise, then pacing your activities of daily living, workload (if you are working) and emotional interactions may help.
Tob help, you can read my previous blogs:
Or listen to the podcasts:
- How To Exercise If You Have Chronic Fatigue
- Building Exercise Tolerance and Capacity with Chronic Fatigue
- Pacing Matters
2. Support Your Nervous System
Physiology aside, sometimes the reaction that we have to some form of physical challenge, often exercise, can be due to a fear response in the body. To give an example of this I would like to share a story of my client, we’ll call her Jane.
Jane had been struggling with post-exertional malaise and her activity levels were limited to taking care of her two toddlers and some walking. She really wanted to expand her physical capacity so she decided to try a short yoga video. Initially she watched the yoga video but did not actually physically follow the video. Watching the video alone, without any physical exertion, was enough to trigger a “post-exertional response”, despite the fact that no exercise was performed.
This is a beautiful example of what we refer to in Somatic Experiencing as an “over-coupling”. Overcoupling is when two things are strongly linked together on a nervous system level and therefore they go hand in hand. In this case, exercise and fear.
In this scenario, resilience and exercise tolerance will increase as the nervous system is able to uncouple exercise and fear. We cannot do this cognitively, it must be done by exploring the sensations in the body and by working with the fear response so that when you go to exercise, there may be a sense of confidence, safety or even expansiveness, in place of the fear.
Additionally we can reprogram the association to one which is more favourable. We want to create positive experiences around exercise so that the body builds up a memory that says: exercise is safe for me.
The previous point about staying within capacity is a great place to start. Learning tools to support your nervous system more specifically, which is something that we cover in the Nurturing Resilience Membership would be the next great step!
3. Lower the Inflammatory Load
You now know that when oxidative stress is excessive this can increase inflammation, decrease in energy production and cause a deconditioning and a loss of resilience and capacity over time. By pacing and finding the right routine, we can reduce production of ROS (reactive oxygen species) and encourage positive adaptation.
Although exertion creates an acute increase in ROS, we want to address chronic causes of increased oxidative stress which may be due to:
- Infections
- Autoimmunity
- Gut imbalances
- Nutritional deficiencies
- Inflammatory diet
- Exposure to chemicals
Every case is different and yet it would be prudent not to dismiss the importance of this work. Oftentimes people notice a jump in their physical capacity after addressing imbalances in the gut, supporting mycotoxin clearance or even just from cleaning up their diet. Yet again, there may also be no single magic bullet but rather the collective synergy of multiple interventions which support the body and its capacity as a whole. There are some common trends and therefore I discuss these a little more in points 5-7.
In my personal journey I tried and failed at exercise many many times. Initially I feel that supporting my nervous system with some brain retraining was possibly helpful to be able to do some walking. Yet it was addressing my digestion that allowed me to hike for 3 hours. However, despite being able to hike, I was unable to get back into resistance training until I discovered that I was overloaded with Mycotoxins and I was able to address this. It was a gradual process of addressing physical imbalances, expanding my capacity, reaching a plateau and then finding more physical imbalances to address.
4. Increase Anti-Oxidant and Anti-inflammatory Support
Post-exertional energy crashes are often related to increased oxidative stress. When we exercise we need to make more energy in the mitochondria. When the mitochondria make energy, they also make reactive oxidative species (ROS) as a byproduct. When the mitochondria are not functioning optimally, the body is deconditioned and/or the inflamed (due to other reasons mentioned above), the amount of oxidative damage produced from exercise can be overwhelming. This oxidative stress uncouples mitochondria, inhibiting energy production and you experience this as Post-Exertional Malaise.
We can mitigate these energy crashes by pacing, supporting the nervous system generally and uncoupling fear from exercise more specifically and by addressing root causes of inflammation and oxidative stress. Additionally we want to incorporate antioxidant and inflammatory support to help the body even more!
The foundations of anti-oxidant and anti-inflammatory support for the body are going to be a good diet with a great balance of unprocessed protein, fats and carbohydrate, colourful plants and optimal blood sugar regulation. Learn more about how to eat for energy here.
Once you have your food-first foundations in place you can then add in extra-anti-inflammatory support and anti-oxidant support. Here are some of my favourite choices:
- Liposomal Glutathione
- Curcumin
- Hydrogen Water
- N-Acetyl Cysteine
- Creatine
- Fish oil with pro-resolving mediators which are designed to support the body’s natural ability to respond to physical challenges and “resolve” the initial steps in the natural inflammatory processMy favourite products are curcumin (the active ingredient in turmeric) and glutathione, one of the body’s major antioxidants.
You can also check out my previous blog where I discuss supplements to support exercise performance and recovery. I like to use a combination of Creatine, Branch Chain Amino Acids and Electrolytes before, during and after workouts.
5. Support Your Adrenal Glands
The adrenal glands are small glands situated above the kidneys that are responsible for releasing stress hormones such as cortisol, DHEA, epinephrine (adrenalin) and norepinephrine (nor-adrenalin). The adrenal glands are made up of the adrenal medulla and adrenal cortex. These hormones are very important for regulating metabolism, the immune system and managing inflammation, maintaining blood pressure, supporting circadian rhythm and helping the body respond to stress.
Wear and tear on the adrenal glands can result in adrenal hypofunction, which is when cortisol production is lower than optimal and can result in symptoms such as:
- Difficulty staying asleep
- Craving salt
- Being a slow starter in the morning
- Afternoon fatigue
- Low blood pressure
- Dizziness when standing
- Afternoon headaches
- Headaches on exertion or with stress
- Hypoglycemia
When adrenal output is compromised, small stressors can have a big impact and this can be a contributing cause of post-exertional malaise and energy crashes. To have more stability and resilience around exertion we can support the adrenal glands with diet, lifestyle and supplements. Top picks mights include:
- Blood Sugar Management
- Electrolytes and proper hydration
- Morning light exposure
- Adrenal adaptogens and glandulars
You can read the full blog on supporting your adrenal glands here.
6. Stabilise Blood Sugar
Blood sugar and adrenal dysfunction often go hand in hand. When adrenal output is low, the body lacks the natural counter regulatory mechanisms to keep blood sugar stable. Exertion can increase fuel demands, further destabilising an already unstable system.
To avoid PEM we want to stabilise blood sugar across the day. This is a foundational step for energy in general and one of the Foundational Five Methodology.
You can learn more about blood sugar stability in the following articles or join the Nurturing Resilience Membership and take the blood sugar course.
- Carbohydrates, Blood Sugar, Glucose Monitoring and Chronic Fatigue
- Hypoglycemia: How to Assess and Address Low Blood Sugar in Chronic Fatigue
Conclusion
Post exertional malaise can be tricky, but with the right strategy it is possible to mitigate and even avoid! Little by little you can expand your capacity and be able to do more without the dreaded payback. It can be overwhelming sometimes to know where to start so I created a FREE Chronic Fatigue Quiz to steer you in the right direction.
