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How long does PEM take to kick in?

Discussion in 'Post-Exertional Malaise, Fatigue, and Crashes' started by fla, May 2, 2011.

  1. fla

    fla Senior Member

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    It's hard to always stay in the energy envelope and regularly I push too much and get PEM (which for me is feeling horribly sick with 9/10 pain level headaches).

    Even after 10 months of this I still haven't figured out exactly how long the delay between the activity that triggered the PEM and the PEM onset.

    • Activity A
    • Rest time A
    • Activity B
    • Rest time B
    • PEM onset
    Sometimes if rest time B sounds like my normal PEM delay I'm surprised because Activity B may be small even for me. I guess it's more of a running total or "battery level" than the difficulty of a particular activity. Kind of a hard question given the energy envelope varies and the recovery rate also varies.

    To simplify the question, starting from a very rested state, if you perform an activity that obviously exceeds your envelope, how long until the PEM kicks in?
     
  2. icalla

    icalla

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    I've found that it varies greatly, but will most often, when I REALLY push it, not kick in until the next day. Sometimes up to 48 hours. My solution is that when I make the decision to push it, for whatever reason, I make sure the following two days are totally clear.

    With lesser activities, or lesser pushing of the envelope, I find it hits faster, but it also doesn't last anywhere near as long.

    So it seems the more extreme the push, the longer it takes for the PEM to kick in, and the longer it lasts.
     
  3. leaves

    leaves Senior Member

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    for me crash starts at 48 hours and it lasts.. long, I will have setback for at least 2 weeks.
     
  4. ukxmrv

    ukxmrv Senior Member

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    24, 48 or 72 hours later for the main severe crash of the PEM with some symptoms starting straight away
     
  5. lucy

    lucy Senior Member

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    Is it then similar to DOMS (starts 24, peaks 48, resolves in 4-7 days)? Could there be two types of crash - PEM and DOMS (with overlap possible)? Still, it would be interesting to know if it kicks in when enough chemicals are produced in the body in response to activity A? In the DOMS case, it could be the response to bradykinin or/and NGF.
    In my case, I have quite an easy PEM, but very cruel DOMS, which can be unbearable at 48 hrs if I have to move the muscles affected. Strangely, DOMS in arms lasts only two days, legs 5-7days.
    An interesting test would be passive muscle usage test, if it exists. If it would be possible to make the muscle be used without the intention, and still get PEMS, all the psychiatrists would be quite unhappy.
    Fla, as for activity B, I suppose you would have to check if maybe only act A is enough to cause PEM. Funny enough, people with CFS do not have to worry about adaption of the body to an activity.
     
  6. fla

    fla Senior Member

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    I didn't know the term DOMS before (thanks wikipedia) and I never have enough energy to exercise enough to provoke DOMS anymore. The only muscle pain I get are heart/chest pains after prolonged high heart rate/POTS. I never thought to look back as far as 72 hours. Maybe some of my unexplained PEM's can become explained it I look into the past a little farther. Very interesting concept that the delay for PEM to kick in can be affected by the intensity of the activity. I'll have to keep an eye open for that too. You guys are great! :thumbsup:
     
  7. PoetInSF

    PoetInSF Senior Member

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    SF
    DOMS is thought to be caused by micro tear of muscle fiber. PEM on the other hand is not. There was a paper that performed MRI and concluded that DOMS and PEM are not the same thing. I'll post it if I find it.

    To answer the OP, the PEM delay has been variable for me depending on the type of exertion and the stages that I am in. But the delay and the severity after the same exercise has been very precise. And it seems to me that, the more it is delayed, the longer lasting it is.
     
  8. WillowJ

    WillowJ Senior Member

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    is DOMS related to fibro? That's usually what I think of, when I have bad pain the next day. The pathology sounds the same, too.

    I can't figure out how to predict when PEM will hit or how to predict how much activity will trigger a flare, either.
     
  9. pamb

    pamb Senior Member

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    For my PWC hubby, DOMS is still as normal (he's an ex competitive athlete, so knows DOMS well), next day and then worse on the second day, easing up after. No big deal generally, as he also does not have the energy to provoke much of it these days.

    PEM is almost always 48 hours after, and severity is related to effort expended. Much worse if he over-extends two days in a row, as PEM from A is percolating, then he does B before A caused PEM hits, and adds the B on top of the A for the 48 hour point. At least that is how it seems.
     
  10. lucy

    lucy Senior Member

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    fla, for me sometimes I did not have to do anything hard to provoke DOMS - a simple activity like cutting 50 cm cardboard with scissors would give me doms in the muscle of the thumb (never knew there was some muscle there). Or a walk down the hill of 50 m would leave me crying when taking the stairs down, resolving after 7 days. Half a year ago I was testing DOMS on the same amount of walking for several weeks without the slightest improvement, which normally happens with sports.
    I had also better times, when I walked down 300 m and nothing, so it really variates, but I cannot figure out what it depends on. I am now much better and DOMS is only sometimes kicking in (the changes I made were quitting the job, so quite a few stressors like the heat in the office, constant mental activity, sitting all the time etc were removed).

    PoetInSF - I was reading this article "Bradykinin and Nerve Growth Factor Play Pivotal Roles..." about hyperalgesia. I hope similar research could be done to find out more about the chemistry of PEM. The article does not say microtears are not players in the game, therefore I don't know how these theories go along.
    In fact I found it hard to find other people on internet with a DOMS as mine, except PoetInSF, you mentioned earlier that you have one. In general I have understood I have different subset of symptoms, which are most probably related to my autoimmune system problem, but I stay here in the forum, as I find all the discussions very useful, hoping I can be useful too.

    Another question to people here would be- does your PEM set in gradually (as DOMS does) or it hits you in the course of let us say 1 hour? My theory would be - if it sets in gradually, then the body is producing something, or reacting chemically to something what was produced during the activity. Therefore it is not a good idea to continue activities, because only more of the evil matter will be produced in our bodies.

    WillowJ - fibro, as I understand, is very much defined by specific points of pain, which I for example do not have. In the beginning, for a half a year, I had one point in the back which was sore and tense, the muscle there was like a small stone under the skin and it would not give up to massage. Now it manifests only with sharp pains there, quite rare. So I dunno how much my doms is related to fibro.
     
  11. icalla

    icalla

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    I don't get DOMS at all. Just the PEM.
    As to the onset on the PEM, it's pretty sudden. Just like initial onset was for me.
     
  12. ukxmrv

    ukxmrv Senior Member

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    The WIKI on DOMS says that the pain only occurs when the muscle is stretched and not at rest. It also states that DOM feels better intitally with more exercise. Also that it can in part be helped by gradually increasing exercise.

    PEM is different. Dr Ramsay who described the PEM in ME wrote about how further activity made the PEM worse and the recovery time longer. He described it as becoming cumulative.

    This could be important as a way of determining between people who respond to a graded exercise program and those who are made worse.
     
  13. Graham

    Graham Senior Moment

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    I'm not sure that my comments here will help clear the issue, but here goes. I used to be a teacher - lots of walking around, but not much in the way of strenuous physical stuff - but also did a lot of big DIY and gardening, so I regularly got bouts of DOMS - delayed onset muscle something-or-other. I gather it is mainly from unusual stretching actions, rather than pulling in with your muscles. It is very different from PEM - post exertional malaise. In that situation I don't just get muscle pain, but total lethargy. That normally kicks in a day after, and how long it lasts depends on how much too much I did. The other interesting bit for me is that mental strain following a bit too much exercise increases the PEM quite a bit. It doesn't happen too much these days because after 12 years I've got into the swing of things, but this week my sister came over from Canada, and we took the dog out for a slow walk on Monday afternoon - normally I can manage half-an-hour (yes, I really do know how lucky I am to be able to manage that) - but this time I probably took three-quarters of an hour. Then, the next day we went to the local support group coffee morning: there were several people there so the chattering was prolific. I'm still feeling the after effects, but I think I would have been OK if I had skipped the coffee morning.
     
  14. WillowJ

    WillowJ Senior Member

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    the current diagnostic criteria involves poking the patient to see if certain spots are unusually painful for a small poke. they say they are going to replace this, but I don't know with what. the pain symptom you would notice without being poked to assess for tender points, is pain in at least 3 quadrants of your body.

    about PEM, you are right, lucy, that the body is producing something or reacting to something to cause this. we know it produces an overload of oxidative stress (damage from free radicals) in the cells, and we believe it produces an immune reaction, and the result of this seems to be reduced cardiopulmonary function. This part isn't PEM, but with muscle use in ME/CFS there is also an increase in neuromuscular dysfunction, similar to what you would see in myasthenia gravis.
     
  15. sickness

    sickness

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    For me it seems that if I use a muscle at all, it will hurt the next day. Even if the activity is something I do all the time. It really is a case of the more I do, the more I hurt.
    As far as PEM goes, I will pass out very heavily immediately after overdoing it. Feel very shaky etc, and often get chills (almost like I have used up all available energy, and my body can't even keep itself warm any more). The next day is when the true PEM kick in, however. Then I feel sick, sore and utterly exhausted.

    take care, ness
     
  16. mellster

    mellster Marco

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    PEM usually kicks in after 12-24 hours and feels very different from DOMS (brutal fatigue vs muscle tissue pain), but DOMS could maybe be taken as a warning for PEM to come. And yes it seems to be cumulative with too much exertion and unrefreshing sleep. I can tolerate eventual moderate, sometimes strenuous exercise, just not in the frequency and intensity I used to. I think it is possible to build up again, but with baby steps only. Also switching activities might help a lot a repetitive activity seems to exascerbate it.
     
  17. PoetInSF

    PoetInSF Senior Member

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    PEM does not set in gradually. If it did, we'd know when to stop. Because it doesn't, we overdo and hence push-and-crash. There were many times early on that I woke up in the morning thinking I'd be fine, and then as 24 hour rolled on I got knocked out.
     
  18. ixchelkali

    ixchelkali Senior Member

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    For me, DOMS and PEM aren't at all alike, and different still from fibromyalgia. I'm not sure if I can describe the difference, but I know it when I feel it. DOMS is like, well, sore muscles, and it does start about 24 hours after whatever caused it. With fibro pain, there's the hurt-all-over pain that comes when I overdo (like a trip to the supermarket, for example). That feels like all the nerves in my body have been set on "pain," so it feels like everything hurts, even my eyeballs, even my hair. That happens immediately after the activity and is gone by the next day. Then there's another kind of fibro pain that often comes from inactivity: that starts in tender points that hurt if you poke them, and radiates out from there. It can be just one or two points or many, and the pain moves around. That seems to improve with very gentle stretching and/or massage. There's even another fibro pain that comes more with cold, damp weather; it feels like arthritis, except in the muscles, and there's stiffness with it.

    PEM is quite different (at least for me). It is a flu-like feeling. That is, it feels like I'm sick. I feel vaguely feverish, sometimes with chills. I often get swollen, tender glands with it, and a slight sore throat. I have to lie down, because it's too hard to hold my head up. I'm exhausted, and even getting up to get a drink of water is hard. I sleep during the day (which I don't otherwise do), and it doesn't keep me from sleeping again at night. My brain is very foggy, my eyes hurt. I ache all over. Really, it's pretty much like what having the flu felt like in my pre-ME/CFS days.

    To answer the original question, PEM for me starts from 24 to 48 hours after the exertion, usually closer to 48. It lasts for days or even weeks. It can be brought on by one big activity where I can't stop when I start feeling tired, like a trip to the store or a doctor's appointment. Or it can be from a slightly higher than ideal level of activity over time, a cumulative effect, or from too much mental work. Anything that might provoke an adrenaline response can trigger it, like getting upset or sudden pain (I got it once from falling and whacking my knee, and another time from having to jump out of the way of a skunk that was preparing to spray). Sometimes it seems to be for no reason at all. I suspect it might be from a hidden stressor, like being exposed to cold germs or something, so there's an immune response working. Even the weather can bring it on, if it is too cold or too hot for several days on end.
     
  19. taniaaust1

    taniaaust1

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    nods yes I often find it is a running total of what one has been doing for past few days.. the day before and the day before that is also playing a part too so when trying to work out how much to do, one also needs to take in account the previous days activities as well. If you dont keep in account of previous days too.. it is hard to pace right.

    It really isnt as simple as just looking at that one day unless you have worked it all out what you are okay with and are doing basically the same each day. Even going very slightly over ones limit will be enough to set off PEM.

    I get hit twice over with symptoms ... I get symptoms which start to come in while doing the activity which get worst the more I do. I think a lot of those are due to POTS coming in. It can often be other symptoms other then exhaustion which put an end to my activity eg dizziness, falling over as suddenly I start loosing balance etc etc. IF it wasnt for these other symptoms, I probably could continue. Then I come good while resting. Then PEM can hit the next day or 48 hrs or so after. PEM can hit up to 3 days after events but in my own case it usually sometime the next day (can happen for me earlier then 24hrs.. it may hit me at the 16-18 hr mark).. or occassionally the day after that.

    It can only be a slight over do of my normal activities which can cause PEM for me. eg Im fine with 45mins gentle continous activity but if I do 15mins more in that session... I risk PEM. Where as if I do the 45 mins in the morning and another 45mins in the afternoon.. I'll get away with doing all that activity without PEM. So the rest times in between are very important in my case.. and keeping things shortish.

    Going 15 mins more over 45 mins Im safe with on Friday.. caused me to have PEM on Saturday and Sunday (so I did nothing at all just trying to allow myself to recover.. didnt even make proper meals for myself) making me go from my normal 8hrs sleep to 12 hrs sleep and still waking up tired. Im only just fine again today (Monday) but cant do my normal 45 mins of activity... I only today lasted 30 mins before a slight headache started, so I guess Im still down some from Friday still.

    It so sucks that extra 15mins activity on Friday knocked me about that bad that it took my whole weekend from me. (I was aware I was probably overdoing it at the time but really really wanted my garden patch finished so pushed myself for 15mins). It WAS worth it.. that patch had been all weedly for about 9mths and bugging the heck out of me.
     
  20. fla

    fla Senior Member

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    I've noticed that my sleep quality, which is always poor, gets significantly worse after a day where I pushed the envelope either physically or mentally. Results in more difficulty falling asleep, frequently waking up, and completely waking up early.
     

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