What Is Pacing in CFS/ME and Long COVID? A Practical Guide to Avoiding Crashes
If you have long COVID or Chronic Fatigue Syndrome/Myalgic Encephalomyelitis, you may have been told to “pace yourself” or heard that “pacing” is really important. But those simple words don’t really explain what this actually means, why it’s necessary, or most importantly, how to actually do it.
We’ll cover all of that in this blog post.
Who am I and why should you care what I have to say about pacing?
Hi, I’m Dr. Arlie, ND. I’m a naturopathic doctor based in Toronto, and I work with people across Ontario virtually, supporting those navigating long COVID, CFS/ME, and other forms of complex chronic fatigue.
What does pacing mean in CFS/ME?
Pacing is the art of using your energy wisely by exerting yourself only as much as you’re able to tolerate, and resting proactively.
In CFS/ME, your energy is significantly limited compared to what you’re used to being able to do, and you can trigger delayed symptom flares known as post-exertional malaise (PEM) by overdoing it. Pacing is identifying how much physical and mental exertion you’re able to tolerate each day, and planning your daily activities to stay within this “energy envelope”. This helps you avoid PEM, crashes, and symptom flares.
Why is pacing important for long COVID and chronic fatigue syndrome?
There are three broad reasons you want to avoid triggering PEM, if you can help it:
It sucks.
A bad flare can set your baseline back, which means you may not recover to the capacity you had before the flare, leaving you with lower energy and more symptoms long-term.
Repeated flares/crashes make it much harder to improve your capacity.
Conversely, effective pacing helps prevent unpleasant PEM symptoms and eventually is the key to increasing capacity.
That may sound counterintuitive - how can you increase your capacity if you never challenge yourself?
When you’re able to pace effectively, and stick within your energy envelope, you get to experience a degree of stability in your symptoms that may feel impossible when you’re not pacing yourself. From that place of stability and predictability, your body is able to start healing, your nervous system starts to feel safer, and eventually you can start to slowly “push the envelope” and increase how much you can tolerate each day.
How do you pace with CFS/ME or long COVID?
OK, so this sounds great, right? But how do you actually do it?
Step One: track your activity and symptoms
Use a paper or digital tool to keep track of your activities and your symptoms for at least two weeks. You can use a wearable biometric tracker like a smart watch or a fancy app to help with this, but a simple log works just fine as well.
Step Two: find your baseline and energy envelope
Analyze your activity log to determine:
How much physical activity can you tolerate per day?
What types of physical activity do you tolerate better than others?
How much mental activity can you tolerate per day?
Are there certain types of mental activity that are more challenging than others?
This step is really important, and can be tricky to do on your own. I often spend a fair amount of time going through this data with my patients to tease out the patterns that are hard for you to step back enough to see.
Step Three: stabilize before increasing activity
Once you know how much exertion you can tolerate each day, it’s time to structure your life to allow you to stay within that envelope. This is much easier said than done.
It’s common to take several weeks or even months to make the practical and mindset shifts that are necessary to establish a consistent, stable base pace.
Once you’re able to maintain this pace, and only experience a crash if something truly unexpected comes up, you can shift your focus to other areas that need your attention. With my patients, we take this opportunity to address all the other areas of your health that have gone off the rails since you got sick. We work on your gut health. We calm your overactive immune system. We support your mental health. We work towards nourishing your body with food.
Once your symptoms are more stable and you have addressed the factors that may be affecting your overall health, many people are able to gradually expand their activities with careful pacing.
Step Four: slowly increase capacity (“pacing up”)
This is the part that half my patients want to do RIGHT NOW and half find too spooky to even consider.
When you’ve been able to maintain a base pace consistently, and your body is supported enough in other ways, you’re ready to start increasing your capacity.
How you actually do this is up to you.
Some of my patients choose to slowly add in exercise to regain strength, stabilize hypermobile joints, and rehabilitate the cardiovascular system.
Some choose to prioritize work, school, or caring for their families.
Other choose to devote their extra capacity to hobbies, socializing, or other joyful activities.
But regardless of what you choose to add in, the principle is always that same: slow and steady. The idea here is to increase your activities just enough to push the top of the energy envelope without triggering a crash. This successful increase in activity not only builds strength and brings joy, but also proves to your nervous system that you’re capable of more. That it’s safe to do more.
And that’s where the magic happens.
Common pacing mistakes
Relying on external markers
It’s common for physiotherapy-based long COVID programs and biometric-based pacing apps to rely pretty heavily on measurements like heart rate to determine your pacing. This can be extremely helpful, but can become misleading in a few situations:
Mental and emotional exertion can play a huge role without significantly raising your heart rate.
People with POTS can have significant heart rate elevations without major exertion.
People on medications that affect heart rate, including stimulants for ADHD, and beta blockers for POTS may get unreliable data.
Being too strict about it
Pacing is an art, not a science. CFS/ME is dynamic, which means your capacity can change day-to-day without an obvious explanation. It’s more effective to know your early warning signs of overexertion and listen to your body than it is to force yourself to follow the exact plan every day.
Never pacing up
It’s scary to suddenly develop a debilitating illness that changes your life overnight. It’s scary to do something you used to be able to do easily and end up flat on your back, unsure if you’ll be able to recover. It makes sense to be scared to push your limits, especially when you have seen over and over again how much worse you feel when you push yourself.
And it is also true that it is possible to slowly and safely improve your capacity if you have the right support.
How the BestPace Method approaches pacing
I called my methodology for treating CFS/ME and long COVID the BestPace Method because pacing is really foundational to managing these conditions. It’s also not the only thing to consider. A really thorough assessment, nervous system support, good nutrition, and real care for your gut health and immune system are also necessary to take pacing from something that just manages your symptoms to a tool for truly improving your capacity and returning to activities you enjoy.
If you’re looking for whole-body support for complex chronic fatigue in Ontario, I can help. Book a free 15 minute discovery appointment to learn more.
FAQs
What is pacing in ME/CFS?
Pacing is a strategy used in ME/CFS and long COVID to balance activity and rest within your available energy limits. The goal is to avoid post-exertional malaise (PEM), create more symptom stability, and gradually rebuild capacity when appropriate.
What is an energy envelope?
Your energy envelope is the amount of energy you have available to you to use throughout the day. In the popular “spoon theory” of disability, your energy envelope is represented by your spoons. Your envelope is dynamic and may expand or contract depending on various factors.
What is post-exertional malaise (PEM)?
Post-exertional malaise is a symptom exacerbation that happens after you overexert yourself. Common symptoms include muscle aches (like having the flu), headache, sore throat, lightheadedness, digestive concerns, and fatigue. PEM is one of the defining symptoms of Chronic Fatigue Syndrome / Myalgic Encephalomyelitis.
Can pacing help long COVID?
Yes, pacing is the mainstay of long COVID treatment. Most people with moderate to severe long COVID meet criteria for Chronic Fatigue Syndrome / Myalgic Encephalomyelitis, which is best managed through pacing.
Can pacing increase my energy?
Pacing on its own can’t increase your energy, though it can prevent the frequent crashes you get when you don’t pace. Once your have stabilized your symptoms through pacing, you may be able to increase your energy through careful “pacing up”.
Is pacing the same as resting?
Pacing is a careful combination of rest AND activity. When you know how much activity you can tolerate, you can safely include some exertion, instead of feeling like you have to rest all the time.
How do I know if I am overdoing it?
One of the trickiest things about post-exertional malaise is that it has a delayed onset. This means that it can take at least 12 hours after overexerting yourself before you feel the effects. You can tell if you’re overdoing it by:
Careful observation of past activity, so you can quit while you’re ahead.
Biometrics like heart rate can be good indicators that you need to slow down.
Early warning signs can be subtle, and everyone has different symptoms. If you can identify yours, you may be able to feel when your body has had enough.
Written by Dr. Arlie Millyard, ND, a naturopathic doctor in Ontario with a focus on complex chronic fatigue, CFS/ME, and long COVID care.