Post Exertional Malaise (PEM)

Old male teacher yawning at desk in the school classroom

When recovering from COVID-19, many people notice they have less energy than before. Sometimes, people feel exhausted and have trouble thinking or doing light activities after a small amount of physical, cognitive or emotional effort. This is called Post-Exertional Malaise (PEM).


Some people recovering from COVID-19 experience exhaustion and have difficulty thinking, muscle aches, headaches, and increased fatigue after minimal amount of activity. This can be brought on by a physical, mental, or emotional effort. This is known as Post-Exertional Malaise (PEM), an abnormal, disproportionate response to effort. This extreme exhaustion can occur 24 to 72 hours after activity and can last for days or weeks. PEM is not dangerous itself but it can affect your quality of life.

Old male teacher yawning at desk in the school classroom


The exact causes of PEM are not fully understood. The fact that pacing helps people with PEM suggests that symptoms are not random, but rather due to overdoing activity. If you do more than your body can handle, your symptoms will worsen. On the other hand, if you stay within your limits (what we call the “energy envelope”), you can gain some control.


People with PEM become caught up in a cycle of “push and crash” (periods of overactivity followed by forced rest). When their symptoms are mild, they push to get as much done as they can, which triggers extreme exhaustion. This makes their symptoms worse, which in turn leads to forced rest or a crash. The push-crash cycle leads to discouragement and frustration in these people, who feel like they have no control over their situation.

Brain fog” or cognitive dysfunction (difficulty thinking and concentrating)

Burning sensation on skin

“Flu-like” feelings

Increased chronic fatigue


Heart palpitations

Speech problems

Tinnitus (ringing in the ears)

Trembling or instability of muscles and/or limbs

Chronic pain (muscular or joint)

Headaches and migraines

Loss of appetite

Night sweats or chills

Short-term memory problems

Sore throat and/or laryngitis

Swollen and painful glands

Trembling or instability of muscles and/or limbs

Disturbed sleep pattern (lack of sleep, or need to sleep too much, often with vivid dreams)

Heaviness in the limbs or whole body

Loss of stamina or functional capacity

Orthostatic intolerance (feeling symptoms while in an upright position) or dizziness

Eye symptoms

Heightened sensitivity to sensory stimuli (sound, light or smells)

Muscle fatigue and weakness

Muscle fatigue and weakness

Problems regulating temperature (and feeling cold or hot in the extremities)


The opposite of push and crash is “pacing.” Pacing means that you spread out your activities into smaller tasks with rest periods in between. You need to break the push-crash cycle by resting and not pushing your limits. To help with your recovery, do light activities for a while.

Pacing is a way to approach activity so that you reduce the big ups and downs in your symptoms. Pacing is being smart about how you use your energy.

It’s very important that you not wait until you feel tired before resting. By applying these strategies, you can decrease the frequency and severity of episodes of PEM.

Man lying in bed turning off an alarm clock in the morning at 7am

The benefits of a plan based on pacing strategies include:

More stable and predictable life


Less frequent and intense symptoms


Less forced rest time


Better chance for improvement


Less mental and physical suffering


Greater sense of control


More time for doing what you enjoy

Take Charge of Your Recovery

Learn self-management techniques with other long haulers in the Post-COVID Support Community. Joint now on our Forever Free plan to start your recovery journey today.