Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS)
What is ME/CFS?
Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) is a serious, complex, multi-system condition characterised by profound fatigue that is not improved by rest. It is not a psychological condition, and it is not simply being tired — ME/CFS is a serious long-term, multi-system disease characterised by severe unexplained fatigue that is not improved by rest, accompanied by symptoms related to cognitive, immune and autonomous dysfunction. Disease severity varies from mild to very severe.
The condition affects an estimated 250,000 Australians. It can follow a viral illness — post-viral ME/CFS is well recognised and has received renewed attention in the context of Long COVID — or develop without a clear precipitating event. It affects people of all ages, with peak onset in the 20s to 40s and a higher prevalence in women than men.
Post-exertional malaise — the defining feature
Post-exertional malaise (PEM) — the worsening of symptoms that occurs following physical, cognitive or emotional exertion, typically delayed by 12 to 48 hours and lasting days or weeks — is the hallmark feature of ME/CFS that distinguishes it from other fatigue conditions and that most fundamentally shapes how physiotherapy and exercise must be approached.
PEM is not simply feeling tired after exercise. It represents a pathological response to exertion — a biological intolerance that produces a genuine worsening of all symptoms, not just fatigue, following activity that exceeds the individual's energy envelope. Understanding PEM is essential for anyone managing exercise for people with ME/CFS, because approaches that are appropriate and beneficial for deconditioning or other fatigue conditions can cause significant and sometimes prolonged harm in ME/CFS if they push beyond the PEM threshold.
What about graded exercise therapy?
This is an important and necessary clarification. The 2021 NICE guidelines for ME/CFS specifically removed graded exercise therapy (GET) — a previously recommended approach based on the assumption that deconditioning drives symptoms — from the list of recommended treatments. The evidence review found that GET was associated with worsening of symptoms in a significant proportion of patients, and that the theoretical model underlying it was not supported by the current evidence on ME/CFS pathophysiology.
This does not mean that people with ME/CFS cannot benefit from physiotherapy or should avoid all physical activity. It means that the approach must be fundamentally different from standard exercise rehabilitation, with pacing and energy management as the foundation rather than progressive exercise loading.
What are the symptoms?
Beyond the core fatigue and PEM, ME/CFS produces a wide range of symptoms including cognitive difficulties (brain fog — difficulty with concentration, memory and word-finding), sleep dysfunction (unrefreshing sleep, hypersomnia), pain (widespread musculoskeletal pain, headaches), autonomic dysfunction (including POTS and orthostatic hypotension — both more prevalent in ME/CFS than the general population), and immune dysfunction (recurrent infections, flu-like symptoms). Symptom fluctuation is characteristic and can be unpredictable.
How is ME/CFS diagnosed?
Diagnosis is clinical — based on the symptom history — as there is no definitive diagnostic test. The Canadian Consensus Criteria and the International Consensus Criteria are the most widely used clinical diagnostic frameworks. A GP or specialist physician makes the diagnosis after appropriate investigation to exclude other conditions that can cause fatigue. Physiotherapy assessment should include a comprehensive symptom history, PEM threshold assessment, and functional capacity evaluation calibrated to the individual's current energy envelope.
How can physiotherapy help?
One of the primary goals of physiotherapy in ME/CFS is to help patients establish a manageable activity level and pacing strategy. Pacing involves breaking daily tasks and activities into smaller, manageable segments and avoiding overexertion. A physiotherapist can work with patients to set realistic activity goals.
Pacing and energy envelope management is the foundation of physiotherapy for ME/CFS. Heart rate monitoring during activity — staying below the anaerobic threshold, often quantified as 60% of age-predicted maximum heart rate or a specific heart rate based on autonomic testing — helps patients identify and stay within their energy envelope. Activity diaries, symptom tracking and pacing plans help patients understand their individual patterns and adjust activity accordingly.
For patients with ME/CFS who also have significant musculoskeletal pain, deconditioning, or associated conditions such as POTS or hypermobility, physiotherapy addresses these specific components carefully within the constraints of the energy envelope. Very gentle movement — within what the individual can tolerate without triggering PEM — may be incorporated, but this is entirely different from standard progressive exercise and must be individually calibrated.
Manual therapy for pain management, sleep hygiene strategies, breathing work, and education on activity modification all contribute to quality of life without the PEM risk of exercise-based approaches. For patients with associated autonomic dysfunction, the management principles from our POTS and hypotension pages apply.
Our physiotherapists Yulia Khasyanova and Mauricio Bara have experience in complex chronic conditions including ME/CFS and are members of the Australian Physiotherapy Association. Telehealth appointments are available for patients whose condition limits attendance at the clinic.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) is a serious, complex, multi-system condition characterised by profound fatigue that is not improved by rest. It is not a psychological condition, and it is not simply being tired — ME/CFS is a serious long-term, multi-system disease characterised by severe unexplained fatigue that is not improved by rest, accompanied by symptoms related to cognitive, immune and autonomous dysfunction. Disease severity varies from mild to very severe.
The condition affects an estimated 250,000 Australians. It can follow a viral illness — post-viral ME/CFS is well recognised and has received renewed attention in the context of Long COVID — or develop without a clear precipitating event. It affects people of all ages, with peak onset in the 20s to 40s and a higher prevalence in women than men.
Post-exertional malaise — the defining feature
Post-exertional malaise (PEM) — the worsening of symptoms that occurs following physical, cognitive or emotional exertion, typically delayed by 12 to 48 hours and lasting days or weeks — is the hallmark feature of ME/CFS that distinguishes it from other fatigue conditions and that most fundamentally shapes how physiotherapy and exercise must be approached.
PEM is not simply feeling tired after exercise. It represents a pathological response to exertion — a biological intolerance that produces a genuine worsening of all symptoms, not just fatigue, following activity that exceeds the individual's energy envelope. Understanding PEM is essential for anyone managing exercise for people with ME/CFS, because approaches that are appropriate and beneficial for deconditioning or other fatigue conditions can cause significant and sometimes prolonged harm in ME/CFS if they push beyond the PEM threshold.
What about graded exercise therapy?
This is an important and necessary clarification. The 2021 NICE guidelines for ME/CFS specifically removed graded exercise therapy (GET) — a previously recommended approach based on the assumption that deconditioning drives symptoms — from the list of recommended treatments. The evidence review found that GET was associated with worsening of symptoms in a significant proportion of patients, and that the theoretical model underlying it was not supported by the current evidence on ME/CFS pathophysiology.
This does not mean that people with ME/CFS cannot benefit from physiotherapy or should avoid all physical activity. It means that the approach must be fundamentally different from standard exercise rehabilitation, with pacing and energy management as the foundation rather than progressive exercise loading.
What are the symptoms?
Beyond the core fatigue and PEM, ME/CFS produces a wide range of symptoms including cognitive difficulties (brain fog — difficulty with concentration, memory and word-finding), sleep dysfunction (unrefreshing sleep, hypersomnia), pain (widespread musculoskeletal pain, headaches), autonomic dysfunction (including POTS and orthostatic hypotension — both more prevalent in ME/CFS than the general population), and immune dysfunction (recurrent infections, flu-like symptoms). Symptom fluctuation is characteristic and can be unpredictable.
How is ME/CFS diagnosed?
Diagnosis is clinical — based on the symptom history — as there is no definitive diagnostic test. The Canadian Consensus Criteria and the International Consensus Criteria are the most widely used clinical diagnostic frameworks. A GP or specialist physician makes the diagnosis after appropriate investigation to exclude other conditions that can cause fatigue. Physiotherapy assessment should include a comprehensive symptom history, PEM threshold assessment, and functional capacity evaluation calibrated to the individual's current energy envelope.
How can physiotherapy help?
One of the primary goals of physiotherapy in ME/CFS is to help patients establish a manageable activity level and pacing strategy. Pacing involves breaking daily tasks and activities into smaller, manageable segments and avoiding overexertion. A physiotherapist can work with patients to set realistic activity goals.
Pacing and energy envelope management is the foundation of physiotherapy for ME/CFS. Heart rate monitoring during activity — staying below the anaerobic threshold, often quantified as 60% of age-predicted maximum heart rate or a specific heart rate based on autonomic testing — helps patients identify and stay within their energy envelope. Activity diaries, symptom tracking and pacing plans help patients understand their individual patterns and adjust activity accordingly.
For patients with ME/CFS who also have significant musculoskeletal pain, deconditioning, or associated conditions such as POTS or hypermobility, physiotherapy addresses these specific components carefully within the constraints of the energy envelope. Very gentle movement — within what the individual can tolerate without triggering PEM — may be incorporated, but this is entirely different from standard progressive exercise and must be individually calibrated.
Manual therapy for pain management, sleep hygiene strategies, breathing work, and education on activity modification all contribute to quality of life without the PEM risk of exercise-based approaches. For patients with associated autonomic dysfunction, the management principles from our POTS and hypotension pages apply.
Our physiotherapists Yulia Khasyanova and Mauricio Bara have experience in complex chronic conditions including ME/CFS and are members of the Australian Physiotherapy Association. Telehealth appointments are available for patients whose condition limits attendance at the clinic.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
