Barhorst, Ellen E, Andrae, William E, Rayne, Tessa J et al. · Medicine and science in sports and exercise · 2020 · DOI
This study reviewed 37 research papers that measured how hard exercise feels to people with ME/CFS and fibromyalgia compared to healthy people. The researchers found that people with these conditions consistently felt that exercise required significantly more effort, even when their heart rates and physical performance were similar to healthy controls. This difference was large and consistent across most studies, suggesting that something about how the brain perceives effort may be affected in these illnesses.
Understanding that ME/CFS and fibromyalgia patients genuinely perceive exercise as more effortful—not just report it differently—validates patient experiences and redirects clinical focus toward investigating the underlying neurophysiological mechanisms. This finding has implications for exercise prescription, rehabilitation protocols, and understanding whether central nervous system signaling or peripheral feedback contributes to post-exertional malaise and symptom exacerbation in these populations.
This meta-analysis does not establish the cause of elevated perceived exertion—it could reflect abnormal central processing, altered interoception, autonomic dysfunction, muscle metabolite accumulation, or psychological factors. The finding is correlational and does not prove that elevated RPE directly causes symptom worsening or post-exertional malaise. It also does not evaluate whether perceived exertion differs during activities of daily living outside controlled exercise settings.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Barhorst, Ellen E, Andrae, William E, Rayne, Tessa J, Falvo, Michael J, Cook, Dane B, & Lindheimer, Jacob B (2020). Elevated Perceived Exertion in People with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Fibromyalgia: A Meta-analysis.. Medicine and science in sports and exercise. https://doi.org/10.1249/MSS.0000000000002421
BibTeX
@article{mecfsatlas-barhorst-2020-elevated-perceived,
author = {Barhorst, Ellen E and Andrae, William E and Rayne, Tessa J and Falvo, Michael J and Cook, Dane B and Lindheimer, Jacob B},
title = {Elevated Perceived Exertion in People with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Fibromyalgia: A Meta-analysis.},
journal = {Medicine and science in sports and exercise},
year = {2020},
doi = {10.1249/MSS.0000000000002421},
note = {PubMed: 32555018},
url = {https://www.mecfsatlas.com/evidence/barhorst-2020-elevated-perceived},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-25. https://www.mecfsatlas.com/evidence/barhorst-2020-elevated-perceived
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