Pacing in short
Pacing means planning your day so activity stays within your energy limit, the amount you can do without making your symptoms worse. The NICE guideline for England calls this energy management and says activity is never automatically increased but is maintained or adjusted.
What Does the ME/CFS Guideline Say About Pacing?
NICE, which writes clinical guidelines for England, doesn't use the word pacing in its 2021 ME/CFS guideline. Its term is energy management: "a self-management strategy that involves a person with ME/CFS managing their activities to stay within their energy limit, with support from a healthcare professional" (NICE, 2021).
NICE says energy management "helps people learn to use the amount of energy they have while reducing their risk of post-exertional malaise or worsening their symptoms by exceeding their limits." Post-exertional malaise (PEM) is the crash that pacing tries to prevent. The Institute of Medicine (now the National Academy of Medicine) defined it as "an exacerbation of some or all of an individual's ME/CFS symptoms after physical or cognitive exertion, or orthostatic stress that leads to a reduction in functional ability" (Institute of Medicine, 2015).
A related idea in research is the energy envelope. A review by the group that developed the approach describes its aim as helping patients "self-monitor and self-regulate energy expenditures and learn to pace activities and stay within their energy envelope" (Jason, 2013).
Why Does Overdoing It Lead to a Crash?
The video below is about POTS. Our team's model of a crash in it is offered as a comparison, and no ME/CFS study has tested it.
Our team's model compares energy to fuel. In the video, the image is a car floored at 100 miles an hour that feels great until the tank runs dry. The car can't go fast again until it's refueled and has had time to recover.
In that model, a crash is one of 2 problems: output running ahead of the capacity you've built, or recovery not keeping up with that output. The video adds that things like an injury, lost sleep or an illness can lower that capacity further.
The video is about dysautonomia and POTS rather than ME/CFS. The part used here is output running ahead of recovery.
In an observational study of people with ME/CFS, "overexertion was particularly impactful for individuals with higher levels of available energy" (O'Connor, 2019). The study compared groups of people at one point in time, so it doesn't show what happens on one person's good days.
What Is Your Energy Limit?
NICE defines the energy limit as "the amount of energy a person has to do all activities without triggering an increase or worsening of their symptoms" (NICE, 2021). The guideline and studies cited here don't give one tested method for finding that limit, and the PEM definition above ties a crash to exertion without saying how soon after it symptoms rise. NICE describes energy management as "a self-management strategy led by the person themselves with support from a healthcare professional in an ME/CFS specialist team" (NICE, 2021), so working out your limit is a job to share with that team.
What Goes Into an Energy Management Plan?
NICE says to help people with ME/CFS develop a plan for energy management as part of their care and support plan. The plan covers cognitive, physical and social demands, rest, sleep and sensory stimulation (NICE, 2021).
NICE says energy management "uses a flexible, tailored approach so that activity is never automatically increased but is maintained or adjusted" (NICE, 2021). 2 points follow from its wording:
- Keep rest and sleep in the plan.
- Change the plan with your care team.
Should You Push Through Fatigue?
NICE's aim for energy management, quoted above, is to lower the risk of PEM and worse symptoms from going past your limits. It says not to advise people with ME/CFS to exercise outside a program overseen by an ME/CFS specialist team. It also says not to offer any programme "that uses fixed incremental increases in physical activity or exercise, for example, graded exercise therapy" (NICE, 2021).
Our team's short video on pushing through POTS makes the point that for many people, pushing through ends with them collapsed in bed. In that video, the answer is to find out why the heart rate is high and solve that problem.
Does Pacing Help?
The research on pacing is mixed. A 2023 scoping review found 17 studies of pacing in ME/CFS: "Eleven studies reported benefits of pacing, four studies reported no effect, and two studies reported a detrimental effect in comparison to the control group." Only 3 of the 17 were randomized controlled trials, and the authors rated the methods "poor to fair" and called for more research on pacing (Sanal-Hayes, 2023). Our PEM recovery guide covers pacing during and after a crash.
NICE says energy management "is not curative" (NICE, 2021). For how our team approaches ME/CFS, see ME/CFS care at the clinic.
See how our team tests upright regulation in 3D
Watch brain blood flow and heart rate respond as you go from lying down to upright.
Take the 3D TourLooking for an ME/CFS evaluation? See how the clinic evaluates ME/CFS.
See ME/CFS carePacing for ME/CFS: FAQ
Is pacing the same as energy management?
Energy management is the term NICE uses in its 2021 guideline for keeping your activities within your energy limit, with support from a healthcare professional (NICE, 2021). NICE doesn't use the word pacing, so it doesn't say the 2 are the same. Energy envelope research uses pacing for a similar aim of staying within the energy you have (Jason, 2013).
Can pacing cure ME/CFS?
NICE says energy management "is not curative" (NICE, 2021). The clinic's ME/CFS page covers how our team approaches ME/CFS care.
What should I do if I've already crashed?
Our guide on how to reverse PEM covers what to do during a crash and how long one can last.
Should I use heart rate to pace?
The authors of a 2023 international survey of people with ME wrote that "there is only one piece of research investigating the use of HRM although a number of guidelines recommend it" (Clague-Baker, 2023). Our POTS guide to heart rate monitors and wearables covers what a watch can and can't show.
Is graded exercise a form of pacing?
Graded exercise therapy raises activity in fixed steps, and NICE says not to offer it to people with ME/CFS, while its energy management approach never increases activity automatically (NICE, 2021).
Sources
- NICE. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (NG206). 2021. nice.org.uk/guidance/ng206
- Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. National Academies Press; 2015. doi:10.17226/19012
- Jason LA, Brown M, Brown A, et al. Energy conservation/envelope theory interventions. Fatigue: Biomedicine, Health & Behavior. 2013;1(1-2):27-42. doi:10.1080/21641846.2012.733602
- O'Connor K, Sunnquist M, Nicholson L, et al. Energy envelope maintenance among patients with myalgic encephalomyelitis and chronic fatigue syndrome: Implications of limited energy reserves. Chronic Illness. 2019;15(1):51-60. doi:10.1177/1742395317746470
- Sanal-Hayes NEM, Mclaughlin M, Hayes LD, et al. A scoping review of 'Pacing' for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): lessons learned for the long COVID pandemic. Journal of Translational Medicine. 2023;21(1):720. doi:10.1186/s12967-023-04587-5
- Clague-Baker N, Davenport TE, Madi M, et al. An international survey of experiences and attitudes towards pacing using a heart rate monitor for people with myalgic encephalomyelitis/chronic fatigue syndrome. Work. 2023;74(4):1225-1234. doi:10.3233/WOR-220512