Cook, Dane B, Nagelkirk, Paul R, Peckerman, Arnold et al. · Medicine and science in sports and exercise · 2003 · DOI
This study compared how hard exercise felt to Gulf War veterans with ME/CFS versus healthy Gulf War veterans. Researchers had both groups exercise on stationary bikes while measuring their effort ratings. People with ME/CFS reported that the same amount of exercise felt much harder than it did for healthy veterans, even though they had similar physical fitness levels.
Understanding how ME/CFS patients perceive exertion during exercise is critical for developing safe exercise guidelines and distinguishing between psychological and physiological contributors to post-exertional malaise. This study provides evidence that elevated perceived exertion may reflect pre-existing fatigue burden rather than a unique perceptual abnormality, which could inform clinical management strategies.
This study does not prove that elevated perceived exertion is purely psychological or that it is an accurate measure of actual physiological stress during exercise. It does not establish causality between baseline fatigue and altered exertion perception, nor does it address whether perceived exertion differences predict post-exertional symptom exacerbation. The findings may not generalize to civilian ME/CFS populations or to other demographic groups.
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
Cook, Dane B, Nagelkirk, Paul R, Peckerman, Arnold, Poluri, Ashok, Lamanca, John J, & Natelson, Benjamin H (2003). Perceived exertion in fatiguing illness: Gulf War veterans with chronic fatigue syndrome.. Medicine and science in sports and exercise. https://doi.org/10.1249/01.MSS.0000058438.25278.33
BibTeX
@article{mecfsatlas-cook-2003-perceived-exertion-2,
author = {Cook, Dane B and Nagelkirk, Paul R and Peckerman, Arnold and Poluri, Ashok and Lamanca, John J and Natelson, Benjamin H},
title = {Perceived exertion in fatiguing illness: Gulf War veterans with chronic fatigue syndrome.},
journal = {Medicine and science in sports and exercise},
year = {2003},
doi = {10.1249/01.MSS.0000058438.25278.33},
note = {PubMed: 12673138},
url = {https://www.mecfsatlas.com/evidence/cook-2003-perceived-exertion-2},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-26. https://www.mecfsatlas.com/evidence/cook-2003-perceived-exertion-2
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