Miwa, Kunihisa, Inoue, Yukichi · International Journal of Cardiology. Hypertension · 2020 · DOI
This study looked at why people with ME/CFS struggle to stand up without feeling dizzy or unsteady. Researchers tested 72 patients and found that balance problems while standing (disequilibrium) were much more common in those who couldn't complete a 10-minute standing test than previously thought. The study suggests that poor balance, rather than just heart rate problems, may be a main reason why standing is so difficult for many ME/CFS patients.
This research challenges the prevailing assumption that orthostatic intolerance in ME/CFS is primarily a cardiovascular problem. By identifying balance dysfunction as a key contributor, it opens new diagnostic and treatment pathways that may help clinicians better manage this debilitating symptom and improve quality of life for patients.
This study does not prove that disequilibrium is the sole cause of orthostatic intolerance—it is likely multifactorial. The cross-sectional design cannot establish causation or temporal relationships for most patients, and the small sample size limits generalizability. The study also does not identify what mechanisms underlie the disequilibrium itself.
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
Miwa, Kunihisa & Inoue, Yukichi (2020). Paradigm shift to disequilibrium in the genesis of orthostatic intolerance in patients with myalgic encephalomyelitis and chronic fatigue syndrome.. International Journal of Cardiology. Hypertension. https://doi.org/10.1016/j.ijchy.2020.100032
BibTeX
@article{mecfsatlas-miwa-2020-paradigm-shift,
author = {Miwa, Kunihisa and Inoue, Yukichi},
title = {Paradigm shift to disequilibrium in the genesis of orthostatic intolerance in patients with myalgic encephalomyelitis and chronic fatigue syndrome.},
journal = {International Journal of Cardiology. Hypertension},
year = {2020},
doi = {10.1016/j.ijchy.2020.100032},
note = {PubMed: 33447761},
url = {https://www.mecfsatlas.com/evidence/miwa-2020-paradigm-shift},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-30. https://www.mecfsatlas.com/evidence/miwa-2020-paradigm-shift
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