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Lifestyle modifications


  • "Energy envelope" is a useful concept in order to teach the patient not to exceed their exertional tolerance. It refers to the total amount of energy that the person has available for daily activities. Using more energy may worsen symptoms. The size of the envelope may vary from day to day (1).

  • Pacing / activity management strategy for CFS/ME patients that prevents and reduces worsening of symptoms. It may include rest between activities, stopping before you feel like stopping, do less than what you think you can do, know your limits, energy saving activities (eg. do not stand if you can sit), planning ahead (1).


  • Graded exercise therapy with gradual increase in exercise frequency, dose and intensity is not recommended by the NICE guidelines (1). However there is a lack of consensus across the world about treatment approaches (1)

  • Include low effort and pleasurable activities (1)

  • Some people may benefit from exercise or an individualized physical activity program for CFS/ME patients (1). The exercise should be of low intensity and not cause post exercise malaise (PEM) (1).


  • A comforting home environment with a supportive family will contribute to the adapation of  appropriate coping and management of CFS/ME (1)


  • Include low effort and pleasurable activities such as observing nature, listening to music, etc. This may improve wellbeing and reduce distress, perception of fatigue, anxiety and depression (1).

  • Cognitive strategies and coping skills to reduce negative emotions and may be useful (1).


  • Normalization of sleep-wake rhythm is recommended and includes stopping day time napping and improve sleep quality, have a good sleep hygiene and assess for undelying causes of sleep problems (1).

  • Cognitive behavioral therapy for insomnia (CBT-i) is recommended for the general population (1). Limited evidence show that CBT-i may help some people with CFS/ME. However CBT-i may also not be tolerated in a portion of people with CFS/ME (2).



Evidence Pyramid


Evidence based on guidelines and evidence based Clinical Decision Systems is written in BOLD

Evidence based on meta analysis or systematic reviews is written in BOLD and CURSIVE

Evidence based on randomized controlled trials is written in plain font

Evidence based on observational / cohort studies is written in CURSIVE

Figure: Evidence pyramid

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