Berentschot, Julia C, Bek, L Martine, Drost, Manon et al. · The Lancet regional health. Europe · 2025 · DOI
This study followed 299 people hospitalized with COVID-19 for three years after discharge to track their recovery. While some improved over time, many people continued experiencing fatigue, memory problems, and cognitive difficulties—and these problems actually got worse between years 2 and 3. About one-third of patients developed post-exertional malaise (PEM), a condition where activity makes symptoms significantly worse, and these patients had more severe and persistent health problems throughout the study.
This study provides crucial evidence that post-COVID conditions share features with ME/CFS, particularly the high prevalence of PEM and the pattern of symptom worsening over time despite initial expectations of recovery. The identification of PEM as a distinct phenotype with identifiable risk factors and worse outcomes supports arguments that PEM-positive patients require specialized management approaches. For ME/CFS researchers, the documented third-year deterioration and concurrent fatigue-cognition-dyspnea cluster offers insights into disease mechanisms relevant to understanding exertional intolerance.
This study does not establish causality between identified risk factors and PEM—only associations. It cannot determine whether PEM in post-COVID patients represents the same pathophysiological mechanism as ME/CFS PEM, as no direct comparison group with ME/CFS was included. The reliance on patient-reported outcomes without objective biomarkers or exercise testing limits ability to distinguish subjective perception from actual physiological dysfunction.
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
Berentschot, Julia C, Bek, L Martine, Drost, Manon, van den Berg-Emons, Rita J G, Braunstahl, Gert-Jan, Ribbers, Gerard M, et al. (2025). Health outcomes up to 3 years and post-exertional malaise in patients after hospitalization for COVID-19: a multicentre prospective cohort study (CO-FLOW).. The Lancet regional health. Europe. https://doi.org/10.1016/j.lanepe.2025.101290
BibTeX
@article{mecfsatlas-berentschot-2025-health-outcomes,
author = {Berentschot, Julia C and Bek, L Martine and Drost, Manon and van den Berg-Emons, Rita J G and Braunstahl, Gert-Jan and Ribbers, Gerard M and Aerts, Joachim G J V and Hellemons, Merel E and Heijenbrok-Kal, Majanka H and CO-FLOW collaboration Group},
title = {Health outcomes up to 3 years and post-exertional malaise in patients after hospitalization for COVID-19: a multicentre prospective cohort study (CO-FLOW).},
journal = {The Lancet regional health. Europe},
year = {2025},
doi = {10.1016/j.lanepe.2025.101290},
note = {PubMed: 40636057},
url = {https://www.mecfsatlas.com/evidence/berentschot-2025-health-outcomes},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-26. https://www.mecfsatlas.com/evidence/berentschot-2025-health-outcomes
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