If the patients have never experienced PEM, do they really have ME/CFS, or perhaps something else?Yes that concerns me. I have two concerns one is what happens to patients who don't have PEM but also what happens to patients who have PEM but with various cognitive issues haven't realized. The latter point is an issue for the diagnostic questionnaires.
Why would they be pacing in the first place, if they didn't experience PEM?I think there is also a point for people who are pacing well how much PEM is actually there. (i.e. if people are avoiding activity to the point where is causes PEM how is this noticed/dealt with in the diagnostic system.