Post-Exertional Malaise: Demystifying This Disruptive Symptom

Ben Ahrens, HHP

Published on

May 15, 2024

Updated on

May 15, 2024

Medically reviewed by

Dr. Robert Stevens

Post-exertional malaise (PEM), also called post-exertional symptom exacerbation (PESE), is a disabling condition experienced by individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), as well as other conditions such as fibromyalgia, post-infection syndrome, long-COVID, and Lyme disease. Post-exertional malaise (PEM) refers to the worsening of symptoms following physical or mental exertion, often lasting for an extended time. 

In this article, we will delve into the neurological aspects of PEM, with a specific focus on the role of interoception and the brain in its development and exacerbation. Most importantly, we’ll explore a novel approach to potentially reversing PEM symptoms using the evidence-based neuroplasticity approach taught in the re-origin brain retraining program. 

If you’re ready to manage your post-exertional malaise, join re-origin’s brain retraining program today.

What is Post-Exertional Malaise? 

According to the United States Center for Disease Control, PEM is a hallmark symptom of ME/CFS, characterized by a profound and disproportionate decline in physical and cognitive abilities after participating in activities that would typically be considered within a person's baseline (normal) activity level. Previously referred to as systemic exertion intolerance disease, this phenomenon can affect daily living, making it challenging for the individual to sustain a consistent level of activity and can significantly impact their quality of life.

Exploring the Role of Interoception and the Brain

In the 2009 paper on Limbic Kindling,1 it is hypothesized that persistent CFS symptoms may both result from and contribute to changes in the limbic region of the brain in CFS patients. More specifically, changes to the function of the insula and the hypothalamus are believed to increase the level of sensitivity to our body’s symptoms and sensations beyond the normal baseline in generally healthy people. 

In other words, the brain can overreact to uncomfortable (but non-dangerous) sensations, which ultimately perpetuates our system into a cascading effect of biochemical and hormonal changes. 

Interoception: The Brain's Awareness of Internal Conditions 

Interoception refers to the brain's ability to perceive and interpret signals originating from within the body, including physiological properties such as heart rate, respiration, and temperature regulation. It plays a crucial role in maintaining homeostasis and coordinating appropriate responses to internal cues. Interoception provides a window into the body's internal conditions and contributes to our awareness of physical sensations.

The Brain and Interoceptive Dysfunction in PEM 

Neurological research suggests that individuals with ME/CFS and PEM may have altered interoceptive processing, leading to post-exertional symptom exacerbation after physical or mental exertion. Studies using functional neuroimaging techniques have revealed abnormalities in brain regions involved in interoceptive processing, such as the insula and anterior cingulate cortex. These regions play a crucial role in integrating interoceptive signals and regulating autonomic and emotional responses.

The Role of the Autonomic Nervous System (ANS):

The Autonomic Nervous System (ANS), which includes the sympathetic and parasympathetic divisions, plays a significant role in regulating interoceptive processes. In ME/CFS and PEM, dysregulation of the ANS leads to abnormalities in heart rate, blood pressure, and other physiological functions. This dysregulation contributes to the variability of physical and cognitive symptoms affecting an individual during PEM episodes.

The Impact of PEM on Cognitive Function:

Individuals with PEM commonly experience cognitive dysfunction or impairment, including sudden and immediate symptoms such as difficulties with memory, attention, and information processing. Research suggests that the brain's interoceptive dysfunction, combined with the impact of PEM on energy reserves and neural resources, contributes to cognitive impairments. 

Interventions and Management Strategies:

Recognizing the role of interoception and the brain in PEM opens up new avenues for potential interventions and management strategies. While research in this area is still evolving, several approaches have shown promise. These include pacing, which involves carefully balancing activity and rest, and graded exercise therapy, which gradually increases activity levels while monitoring symptoms to improve exercise intolerance. 

Additionally, cognitive behavioral therapy (CBT) and pain reprocessing therapy (PRT) can help individuals develop strategies and adapt to the challenges posed by PEM. Furthermore, self-directed neuroplasticity or “brain retraining” approaches involving aspects of PRT and somatic experiencing have been demonstrated to be effective treatments for chronic pain and work by changing the brain’s interoceptive processes.2

The re-origin Neuroplasticity Program 

Members of the re-origin program have applied similar evidence-based approaches and self-reported up to 94% reduction in symptoms, including PEM, in as little as eight weeks of implementing the self-directed neuroplasticity intervention. The program works by establishing five fundamentals of recovery: 

  1. Understanding of the brain’s involvement in the condition. This allows participants to reprocess the uncomfortable sensations of PEM as “non-threatening” 
  2. Consistent conditioning. By repeating an expert-designed protocol, program participants learn to practice and effectively “wire in” a new routine for the brain to follow if or when it encounters uncomfortable stimuli. 
  3. Incremental training - not only serves as a means of pacing and staying in one’s “sweet spot” but also includes aspects of well-established therapies, including gradual exposure and systematic desensitization. 
  4. Pattern interruption in real-time. Through interoceptive and awareness practices, re-origin members learn to remain in contact with their internal feelings and sensations (as opposed to avoiding and steering away from them). Rather than avoid the discomfort, which sends a message of confirmation back to the limbic system, members learn to gently interrupt the pattern, shifting their awareness to a broader context and changing their experience to a more pleasant or natural one. 
  5. Mood elevation. Dr. Martin Seligmen and Dr. Stephen Porges have both written extensively about the physiological benefits of shifting to a more positive mood. Apart from the cognitive reappraisal (reframing negative experiences as catalysts for growth), there are also neurochemical reasons why this may be effective and reducing sensations of pain and discomfort. The brain tends to upregulate the production of so-called “feel-good neurotransmitters” and hormones, including dopamine, oxytocin, serotonin, and endorphins. 

If you are experiencing long-term symptoms of chronic pain or post-exertional malaise, it is important to consult a qualified healthcare provider and rule out any ongoing structural or pathological causes. 

The Importance of Healthcare Providers:

Healthcare providers, including clinicians and therapists, play a crucial role in supporting individuals with ME/CFS and PEM. Accurate diagnosis based on established diagnostic criteria, such as myalgic encephalomyelitis: international consensus criteria, is essential for proper management and decision-making.


What does post-exertional malaise feel like?
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Post-exertional malaise is characterized by a significant worsening of symptoms following physical or mental exertion. It often leads to persistent and disabling fatigue, muscle pain, cognitive difficulties, and an overall sense of physical and mental exhaustion.

What triggers post-exertional malaise?
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Post-exertional malaise can be triggered by activities that exceed an individual's energy threshold. It can result from physical activities such as exercise, as well as mental or emotional exertion, such as engaging in challenging cognitive tasks or stress.

How do I get rid of post-exertional malaise?
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Post-exertional malaise can be managed by pacing oneself, balancing activity and rest, and listening to the body's signals. In addition, gradually increasing activity levels, practicing stress-reduction techniques, and incorporating symptom management strategies may help alleviate symptoms. 

The re-origin program offers online training as well as a community of individuals who are reporting tremendous improvements using this cutting-edge neuroplasticity-based approach.

How do you know if you have post-exertional malaise?
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If you experience a significant worsening of symptoms, such as fatigue, pain, and cognitive difficulties, after engaging in physical or mental activity, you may be experiencing post-exertional malaise. Consulting with a healthcare professional for evaluation and diagnosis is recommended.

Is there a cure for post-exertional malaise?
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Currently, there is no known cure for post-exertional malaise. Treatment focuses on symptom management and improving overall quality of life through a multidisciplinary approach that may include lifestyle modifications, symptom-specific interventions, and support from healthcare professionals.

How long does post-exertional malaise last?
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The duration of post-exertional malaise varies from person to person. It can range from a few hours to several days or even longer. The recovery period depends on individual factors, the severity of the exertion, and overall health.

What can I do to prevent post-exertional malaise?
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To prevent post-exertional malaise, it is important to practice pacing and energy conservation. This involves carefully balancing activity and rest, listening to the body's signals, and avoiding overexertion. Gradually increasing activity levels and incorporating relaxation techniques can be beneficial.

What is the difference between post-exertional malaise and chronic fatigue syndrome?
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Post-exertional malaise (PEM) is a hallmark symptom of chronic fatigue syndrome (CFS). While PEM refers specifically to the exacerbation of symptoms following activity, CFS is a complex medical condition characterized by persistent fatigue that is not alleviated by rest and is accompanied by a range of other symptoms. PEM is one of the defining features used to diagnose CFS.


Ben Ahrens, HHP