Barhorst, Ellen E, Boruch, Alexander E, Cook, Dane B et al. · Pain medicine (Malden, Mass.) · 2022 · DOI
This review examined whether people with ME/CFS and fibromyalgia experience increased pain after exercise. Researchers combined data from 15 studies and found that yes, patients do have more pain after physical activity than healthy people do—especially when pain was measured 8-72 hours later. This confirms that pain is a real and significant part of post-exertional malaise (the worsening of symptoms after activity).
This systematic review provides quantitative evidence that pain worsening after activity is a measurable, consistent feature of post-exertional malaise in ME/CFS and fibromyalgia. This validation is important for recognizing PEM as a core symptom requiring clinical attention and for informing future treatment approaches that minimize exercise-induced symptom exacerbation.
This study does not establish the biological mechanisms causing pain-related PEM, nor does it prove that exercise is harmful for all patients with ME/CFS or fibromyalgia. The findings are based on acute laboratory testing and may not fully represent real-world activity patterns. It also does not compare different types or intensities of exercise to determine optimal activity prescriptions.
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, Boruch, Alexander E, Cook, Dane B, & Lindheimer, Jacob B (2022). Pain-Related Post-Exertional Malaise in Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) and Fibromyalgia: A Systematic Review and Three-Level Meta-Analysis.. Pain medicine (Malden, Mass.). https://doi.org/10.1093/pm/pnab308
BibTeX
@article{mecfsatlas-barhorst-2022-pain-related,
author = {Barhorst, Ellen E and Boruch, Alexander E and Cook, Dane B and Lindheimer, Jacob B},
title = {Pain-Related Post-Exertional Malaise in Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) and Fibromyalgia: A Systematic Review and Three-Level Meta-Analysis.},
journal = {Pain medicine (Malden, Mass.)},
year = {2022},
doi = {10.1093/pm/pnab308},
note = {PubMed: 34668532},
url = {https://www.mecfsatlas.com/evidence/barhorst-2022-pain-related},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-29. https://www.mecfsatlas.com/evidence/barhorst-2022-pain-related
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