page 4 CFS > POST EXERTIONAL MALAISE

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Improving PEM
https://forums.phoenixrising.me/threads/list-of-me-cfs-recovery-and-improvement-stories.80502

 

"Post-exertional malaise (PEM) is the temporary worsening of ME/CFS symptoms which occurs after physical or mental exertion.

 

Many treatments for PEM is found here. The PEM busters in that thread include: corticosteroids, Mestinon, cannabis, D-ribose, BCAA, Q10 and sodium bicarbonate.

 

Prednisolone

 

• ME/CFS patient Hamsterman normally bedbound with severe ME/CFS found a one-off dose of 20 mg of prednisolone taken 30 minutes before a major exertion completely prevents PEM. He found taking prednisolone just before exercise allowed him to do a full workout at the gym without getting any PEM repercussion whatsoever. But he cautions that these doses of prednisolone should not be used daily, only occasionally, as the immunosuppressive effects of daily prednisolone will likely allow underlying viral infections to proliferate.

 

 

Cannabis

 

• Several ME/CFS patients report cannabis is a good PEM shielder and PEM reliever: they find if cannabis is taken just when the first signs of PEM appear, at the first PEM "danger signals", then it will prevent the PEM from fully manifesting.

 

 

Mestinon (Pyridostigmine)

 

• ME/CFS patient Mel9 found Mestinon greatly reduced her PEM. Taking 30 mg of Mestinon once every four hours allows her to have a relatively active day (4 km walks).

 

• ME/CFS patient q with this illness for 28 years found Mestinon 180 mg per day eliminated her PEM, allowing her to do 3 mile runs and go to the gym without any PEM repercussion

 

Supplements and Drugs Which Can Reduce PEM

 

Several supplement and drugs appear to be able to reduce or prevent post-exertional malaise (PEM), by either preventing PEM from physical or mental exertion occurring in the first place, or helping to relieve any PEM that has already appeared.

 

PEM can be caused both by physical exertion, and also by mental exertion (such as hectic social activity). The mechanism of mental exertion-induced PEM may be different to the mechanism of physical exertion-induced PEM.

 

The PEM reducers (aka "PEM busters") on this thread were compiled from other forum threads detailing ME/CFS patients' experiences with supplements and drugs they observed reduced or eliminated their PEM.

 

PEM Reducer Supplements and Drugs

 

The following are the supplements, drugs and other treatments that ME/CFS patients have found reduce PEM, given in approximate order of efficacy (best or most promising PEM reducers at the top of the list):

 

Corticosteroids — taken before exertion can completely prevent PEM; see the corticosteroids section. below.

 

Mestinon (pyridostigmine) 10-180 mg daily— helps some patients entirely avoid PEM.

 

Cannabis — taken just as PEM begins to appear prevents PEM from fully manifesting; see the cannabis section below.

 

D-ribose — 5 grams, three times daily.
author's note: tried for two months had little effect, willing to try again in combination with new regimen

 

Branched-chain amino acids (BCAA) — 5 grams.

 

Co-enzyme Q10 — 800 mg to 1800 mg (this is a very high dose of Q10).
Note that Q10 is most cheaply purchased in bulk powder form

 

Sodium bicarbonate (baking soda) — 2 grams (half of a level teaspoon)."

 

 

 

 

 

"Citrate supplements — 3 grams.

 

Creatine hydrochloride — 2 grams.

 

Citrulline — 1000 mg.

 

Catalase — 600 mg (taken after exercise).

 

Cold therapy — such as a cold bath.

 

Cumin (Cuminum cyminum) — level teaspoon of cumin powder; effects last for 3 days.

 

Chinese skullcap root (Scutellaria baicalensis) — 3 to 6 grams, taken two to three times daily

 

These anti-PEM supplements and drugs are further detailed below.

 

You can try one or more of the above supplements and drugs during PEM itself, or in advance of any physical or mental exertion that you suspect is going to trigger PEM, and see if they relieve or prevent your PEM.

 

Most experienced ME/CFS patients know roughly how long their PEM periods tend to last for, so will certainly notice if a supplement can dramatically shorten the severity or duration of their PEM.

 

PEM Shielders vs PEM Relievers

 

A PEM reducer supplement or drug may fall into one (or both) of the following two categories:

 

PEM shielders help prevent PEM from occurring in the first place. PEM shielders only work properly when taken as a preventative medication before you engage in physical or mental exertion.

 

PEM relievers mitigate the severity and duration of PEM only when taken after the exertion has occurred, where the PEM may already have begun to manifest.

 

It is important to know whether a supplement or drug is a PEM shielder or a PEM reliever, because the former only work when taken before the exertion, and the latter only work when taken after the exertion.

 

As an example of the difference, hamsterman found that the corticosteroid drug prednisolone 20 mg is an excellent PEM shielder for both physical and mental exertion, but found that such corticosteroid drugs do not work at all as PEM relievers.

 

Whereas hamsterman found that BCAA, Q10, creatine and baking soda work more as PEM relievers, rather than PEM shielders.

 

Though TravelChimp said in this post that creatine works for him as both a PEM shielder, as well as a PEM reliever.

 

And SOC said Q10 works both as a PEM reducer when taken at a one-off very high dose of 2400 mg (two 1200 mg doses on the same day), but also found Q10 had some mild PEM shielding effects when taken at a dose of 800 mg daily.

 

Note that this study found 3000 mg of Q10 daily for 8 months was safe.

 

If you are going try these high doses of Q10, you may be better off taking the ubiquinol form, not the more common and cheaper ubiquinone form. This is because blood levels of ubiquinol will continue to rise with increasing dose levels; by contrast, if you take ubiquinone, the blood levels of Q10 will eventually begin to flatten out with increasing dosage. Ref: here.

 

msf found that Chinese skullcap root is a good PEM shielder, at a dose of 3 to 6 grams, taken two to three times daily.

 

One review paper says both baicalin and baicalein (found in Chinese skullcap) and protect mitochondria from oxidative stress. And one study found baicalin restored the infection-triggered decrease in mitochondrial complex V (aka: ATP synthase, or ATPase). Mitochondrial complex V (ATP synthase) has been found deficient in ME/CFS. This might explain the anti-PEM effect of Chinese skullcap root.

 

Chinese skullcap root contains 8 to 16% of baicalin, and 0.2% to 1.2% of baicalein. Ref: 1 So 5 grams of root corresponds to about 500 mg of baicalin. Note that you can buy 95% pure baicalin from LifeMode, costing $19 for 20 grams. Baicalin bioavailability in rats 2.2%, and half-life around 10 hours. Ref: 1 In the body, baicalin converts into baicalein. Ref: 1

 

Wishful finds that cumin (Cuminum cyminum) effectively blocks physical exercise from causing PEM, as well as reducing any PEM that is already present. So cumin appears to be both a PEM shielder and PEM reliever. He finds just 1 level teaspoon of cumin powder blocks PEM for 3 days. This spice contains cuminaldehyde, which has known mitochondrial effects. Unfortunately @Wishful says that no other ME/CFS patients so far seem to have benefited from cumin. See also this thread.

 

Cannabis appears to be a good PEM shielder/reliever, when taken just as the first signs of PEM appear. See the cannabis section below for more details.

 

Some ME/CFS patients find Mestinon (pyridostigmine) taken in doses of 10-180 mg daily eliminates PEM from physical exercise, see here. Dr David Systrom has a clinical trial of pyridostigmine for ME/CFS.

 

Nothing however seems to be quite as powerful as corticosteroids for total PEM shielding.

 

Biochemical Theory of PEM: How the PEM Busters Work

 

The above PEM reducer supplements and drugs were discovered by various ME/CFS patients on this forum, who observed that a supplement or drug they were taking had anti-PEM effects.

 

Interestingly, many of these PEM buster supplements —namely creatine, citrulline, BCAA, Q10, bicarbonate and glutathione — are shown in studies to inhibit exercise-induced lactate. See the athletic exercise performance studies in this post. So lactate inhibition may be the mechanism of action of these PEM busters. Lactate inhibition probably does not apply to D-ribose, cannabis or corticosteroids, which likely reduce PEM by other mechanisms.

 

D-ribose may work by helping to replace ATP molecules that may be lost during significant exertion: in the theory of PEM proposed by Myhill, Booth and McLaren-Howard (briefly explained in this post), it is suggested that PEM is caused by the loss of ATP molecules that occurs when ME/CFS patients exercise.

 

According to this theory, you only get over PEM once the body re-manufactures the lost ATP molecules, which can take many days or weeks — hence why PEM can last for days or weeks. D-ribose speeds up the process of re-manufacturing the lost ATP molecules, thus curtailing the duration of PEM.

 

Myhill, Booth and McLaren-Howard's theory also proposes that a build up of lactic acid during exercise exacerbates and worsens PEM (since lactic acid requires a lot of energy to clear from the body); so that might explain why the above supplements which reduce exercise-induced lactate are PEM relievers: they can help ME/CFS patients get over PEM more quickly.

 

Their theory suggests that lactic acid is not the initial cause of PEM (that's due to a shortage of ATP molecules which deliver energy), but lactic acid build-up from exercise further compounds the energy shortage problem of PEM, because to clear lactic acid by converting it back to glucose, it requires considerably more energy than was originally gained from the conversion of glucose to lactic acid.

 

Patient Accounts of The Anti-PEM Effects of The Supplements

 

This post details how D-ribose powder, at the standard dose of 5 grams taken three times daily, consistently curtails PEM from its usual 3 or 4 days, down to just 12 to 24 hours, for ME/CFS patient @arewenearlythereyet.

 

This post details how for ME/CFS patient @SOC, a very high one-off dose of 2400 mg of co-enzyme Q10 (taken as two 1200 mg doses on the same day) dramatically eliminated a PEM period with 24 hours, a PEM that would normally have lasted 10 to 14 days. The patient also found that 800 mg of Q10 taken daily noticeably raised their PEM threshold (see this post). Cheap sources of bulk Q10 powder are found on purebulk.com.

 

This post details how regular supplementation with creatine monohydrate 10 grams daily increased energy, and allowed ME/CFS patient @TravelChimp to do much more physical exercise before the PEM was triggered; in other words, this patient found the creatine raised their PEM threshold. Not only that, but when they did get PEM by overdoing it, they noticed their PEM was reduced in severity as a result of the creatine supplementation.

 

Note that creatine hydrochloride 2 grams daily may be a much better form of creatine to use than creatine monohydrate, as creatine HCl does not cause stomach aches or fluid retention (as the monohydrate form can), and also is much more water soluble and absorbable in the gut, and so you only need to take around ⅕ of the dose (so 10 grams of creatine monohydrate = 2 grams of creatine hydrochloride; ref: 1).

 

Here is a thread detailing the anti-PEM effects of branched-chain amino acids (BCAAs). @Mary says later in this thread that BCAAs reduce her PEM duration from 2 days to 1 day. It may be the isoleucine in BCAAs that is responsible for the bulk of the anti-PEM affects, as isoleucine significantly increases glucose uptake. See this post. BCAAs have been proposed to alleviate exercise-induced fatigue. Ref: 1

 

Here is a thread detailing the anti-PEM effects of sodium bicarbonate, catalase, glutathione and others. In the thread, @Mya Symons says that sodium bicarbonate taken just before exercise, and 600 mg of catalase taken just after exercise, has the best anti-PEM effect.

 

Citrate supplements (such as sodium citrate or potassium citrate) may be an alternative to sodium bicarbonate; see @Mel9's post below. I would think you need to use doses around 3 grams or so (the sort of dose used for alkalizing). Citrate has the advantage that you can take in on a full stomach, and it will not reduce stomach acid levels (bicarbonate is best not taken when you are digesting food).

 

Here is a post detailing the anti-PEM effects of cold therapy (cold baths or swimming in cold water). @helen1 finds PEM symptoms decrease significantly after cold therapy, especially nausea and weak legs, and finds it is most effective if you catch the PEM early.

 

Studies on these PEM Buster Supplements

 

Athletic performance studies which demonstrate how these PEM reducing supplements also generally improve exercise performance are given in this post. These studies are also listed in Cort's excellent resource about PEM reducers found here.

 

These athletic performance studies found that the very same supplements that ME/CFS patients on this forum have found prevent or relieve PEM also reduce the recovery period after athletic exercise in healthy people. Several of these studies found that the athletic performance-enhancing supplements work via neutralizing exercise-induced lactate circulating in the blood, and this is probably one of the mechanism by which they reduce PEM.

 

Cannabis as a PEM Shielder/Reliever

 

Several ME/CFS patients have reported that cannabis is a good PEM shielder/reliever: they find if cannabis is taken just when the first signs of PEM appear, at the first PEM "danger signals", then cannabis will prevent the PEM from fully manifesting.

 

Cannabis seems to prevent PEM caused by both physical or mental exertion. Patients report that when they have done too much physical or mental activity, and start to sense the "danger signals" that PEM is about to appear, taking cannabis pulls them out of the danger zone, so that they can escape PEM before it manifests.

 

Interestingly, some ME/CFS patients report that moderate doses of cannabis do not produce any high at all. This observation is interesting in itself, as cannabis will normally get people high; but the fact that in ME/CFS, moderate doses of cannabis often do not cause any high is intriguing. And this is good news for patients who would like to benefit from the anti-PEM effects of cannabis, but do not want to experience a high just in order to gain these benefits.

 

To help ensure only moderate doses are taken, Cannabis indica may be the best choice, rather than Cannabis sativa. Indica has less of the THC that gets you high, and more of the CBD which acts to counter some of the effects of THC. Whereas by comparison, sativa has more THC and less CBD.

 

Of course, the legality of cannabis varies from region to region, but this option of using moderate dose of a mild cannabis like Indica to prevent PEM is another useful addition to the list of medications that reduce PEM.

 

In terms of why cannabis has this anti-PEM effect, this article says the THC and CBD active principles in cannabis can affect mitochondria: cannabinoid type 1 receptors (CB1) are found on mitochondria, and THC is an agonist of the CB1 receptor, whereas CBD is an antagonist of this receptor. So maybe that is how cannabis helps avoid PEM, by modulating mitochondrial function.

 

Corticosteroids as Potent PEM Shielders

 

Corticosteroids such as prednisone, prednisolone and hydrocortisone are reported to be potent PEM shielders. When normal doses of these corticosteroids are taken around one or two hours before any physical or mental exertion, they can totally prevent any PEM from later appearing.

 

But these drugs were found to be useless if taken after the exertion. That is, they do not help if you are already experiencing PEM from a previous period of exertion.

 

Note that it is normal doses of corticosteroids (eg, prednisolone 20 mg, or hydrocortisone 80 mg) that can prevent PEM, not the low doses (eg, prednisolone 5 mg, or hydrocortisone 20 mg) that some ME/CFS patients take daily.

 

And note that normal doses of corticosteroids should only be used occasionally in ME/CFS, perhaps as a maximum of once a week. If normal doses are used every day on a long term basis, this can lead to worsening of ME/CFS (possibly because the corticosteroid Th1 immune suppression may allow any underlying viral infections to proliferate).

 

Examples of ME/CFS patients using corticosteroids to prevent PEM:

 

User Patrick found that prednisone at a dose of 20 mg taken a just before a mentally exerting event (such as socializing) was effective at relieving ME/CFS symptoms. Sometimes he would take another 20 mg later in the day. Other ME/CFS patients have vouched this works effectively and reliably (though others report ill effects from this corticosteroid drug). Note that this dosing is only used as a one-off, not regularly every day.

 

User hamsterman found hydrocortisone at a one-off dose of 80 mg (or alternatively and equivalently prednisolone 20 mg) taken 30 minutes before a mentally or physically exerting event very effective for preventing PEM due to physical and mental exertion:

 

hamsterman said:

I tested it hydrocortisone with 80 mgs (equiv. to 20 mgs prednisone), and used it 30 minutes prior to 4 different situations which always cause PEM 1) Doctors visit, 2) engaging chat with friend 3) cardio workout 4) another chat with a different friend. Each time, no PEM.

 

Just as with prednisone, its useless if taken after the exertion, it does nothing if you are already experiencing PEM, is not meant to be taken daily,

 

But unlike prednisone, it hydrocortisone doesnt stay in the system for very long, so after a couple hours or so, it is no longer active. But this can be an advantage, since it can be used more strategically... and more often.... potentially multiple times per week,

Correction: hamsterman told me he was actually using prednisolone and not prednisone as he stated in the quote above. The former takes effect faster.

 

Note that hamsterman said he has the autoimmune disease Crohn's, which causes has extreme fatigue, though thinks he may have ME/CFS as well.

 

User gregh286 found prednisone will block PEM from appearing.

 

How long for the corticosteroid PEM shield to kick in? Prednisone takes around 2.6 hours for the drug to reach peak levels in the bloodstream, whereas prednisolone is faster, taking only around 1.3 hours. Hydrocortisone takes around 1 to 2 hours. Ref: 1

 

So when taking any of these corticosteroids in advance to prevent PEM from a physical or mental exertion you are about to perform, give these drugs enough time to kick in before starting the exertion, else your PEM shield will not be in place. CAUTION: note that there are also timed release versions of prednisone, which only slowly release the drug into your system over several hours, so it might be best to avoid these.

 

What is the dose equivalence of different corticosteroids? Difference corticosteroid drugs have different strengths: hydrocortisone 80 mg = prednisone 20 mg = prednisolone 20 mg = methylprednisolone 16 mg = triamcinolone 16 mg = dexamethasone 3 mg = betamethasone 2.4 mg. Source: here.

 

How long does the corticosteroid PEM shield last? In terms of how long the "PEM shield" lasts, the plasma half-life of prednisone and prednisolone is 3 to 4 hours, and the plasma half-life of hydrocortisone is 2 hours. So once your "PEM shield" is active it will last for say one or two half-lives, ie, your PEM shield may last about 4 to 8 hours for prednisone and prednisolone, and last around 2 to 4 hours for hydrocortisone.

 

When taking prednisone 20 mg, @hamsterman found its PEM protection lasted for as long as 8 hours; but when he tried exercising 13 hours after his prednisone, then he crashed. So for a single 20 mg dose of prednisone, around 8 hours would seem the limit of its protective effects. Of course you could take a second 20 mg dose at the 8 hour point, and get another 8 hours of protection.

 

Efficacy of the corticosteroid PEM shield. This is how effective @hamsterman found a one-off dose of prednisolone 20 mg to be at completely eliminating PEM from a major physical workout at the gym: hamsterman said:

 

Just as a side note, I've been using Prednisone once a week for about a year, and I've found its absolutely impossible to induce PEM while Im on these corticosteroids. I've really taken this to the limit.... doing crazy cardio... things that would normally cause severe multi-week PEM... and each time... nothing. I've also accidentally done a 'double-blind' test, when I accidentally took the wrong medication, and had severe PEM afterwards.

 

Note that hamsterman was using prednisolone and not prednisone as he stated in the quote above. Interestingly enough, after doing this intense cardiovascular exercise once weekly for a year, courtesy of the PEM shielding provided by corticosteroids, hamsterman was able to completely cure his POTS (see here). But his ME/CFS has not improved through exercise. POTS is known to responds well to exercise, whereas ME/CFS does not.

 

Corticosteroids may lead to major problems if taken daily for weeks in a row. If corticosteroids are used every day on a long term basis of weeks, this can lead to worsening of ME/CFS, perhaps because the immune suppression from the corticosteroids may allow any underlying infections to proliferate (corticosteroids reduce the antiviral Th1 response, reduce T-cell function, and increase the antibacterial Th2 response).

 

See the warning in this post, which cautions against using prednisone for any extended period of time, and warns that the PEM protective effects do not work for the whole day, they seem to wear off after about 6 to 8 hours. Prednisone is a strong drug, and has sometimes caused adverse events in ME/CFS patients.

 

Dr Chia says two ME/CFS patients who took prednisone daily for two weeks remarkably improved; but when they tapered off they got much worse, and ended up in the hospital. He believes it such extended use of corticosteroids allows enterovirus to proliferate.

 

The mechanism by which corticosteroids provide a potent PEM shield may relate to their effects on energy metabolism and mitochondrial oxidative phosphorylation. Mitochondria possess a glucocorticoid receptor, and that receptor regulates oxidative phosphorylation. Refs: 1 2

 

Interestingly, the over-the-counter drug theophylline greatly potentiates the anti-inflammatory effects of corticosteroids. Ref: 1 In this study of adding theophylline to the corticosteroid regimen of asthma patients, they used a dose of 250 mg of theophylline daily. Theophylline also has a vasoconstriction effect, and is thus useful for POTS, to reduce blood pooling in the legs on standing. Whether theophylline would help ME/CFS patients get the same anti-PEM effects from lower doses of corticosteroids remains to be seen.

 

Hip - I did a very small dose of creatine once, but was scared off of it by negative things I had read. However, I just read your post linked above where you set out the difference between creatine hydrochloride and creatine monohydrate - I never knew all that, it's great information and think I will give the creatine hydrochloride a try - Thanks for all the info!

 

Mary said: the difference between creatine hydrochloride and creatine monohydrate

Yes, some of the creatine monohydrate is converted into creatinine by the action of the stomach acid on creatine, and this creatinine can have mildly toxic effects, leading to stomach cramps or fluid retention the ankles and legs (this issue can be eliminated, though, if you take creatine monohydrate on an empty stomach where there is minimal stomach acid present).

 

But better still, this problem of conversion of creatine to creatinine in the stomach does not really occur at all with creatine hydrochloride, so creatine hydrochloride seems like a much better form of creatine to take.

 

Creatine in all forms does raise DHT (dihydrotestosterone) though. This study found that in young men, a daily dose of 5 grams of creatine in the form of creatine monohydrate led to a 40% increase in DHT levels. Higher levels of DHT are linked to prostate problems, can exacerbate hair loss (androgenetic alopecia), and paradoxically can increase body and facial hair. So for anyone taking high doses of creatine regularly on a long term basis, you might want to consider also taking a supplement that reduces DHT, such as the herb saw palmetto, which reduces DHT by around 40%. Ref: 1

 

But if you were just temporarily taking creatine during the PEM period, or on the day that you exercise, I don't think you'd have to worry about DHT.

 

Hip said: Yes, some of the creatine monohydrate is converted into creatinine by the action of the stomach acid on creatine, and this creatinine can have mildly toxic effects, leading to stomach cramps or fluid retention the ankles and legs (this issue can be eliminated, though, if you take creatine monohydrate on an empty stomach where there is minimal stomach acid present).

 

But better still, this problem of conversion of creatine to creatinine in the stomach does not really occur at all with creatine hydrochloride, so creatine hydrochloride seems like a much better form of creatine to take.

 

Mary said: I just saw this, don't know if it would be worth trying in addition to the creatine - if the creatine actually helped me, I guess I would probably give something like this a try: https://www.pipingrock.com/hair-skin-nails/dht-blocker-for-men-women-60-coated-tablets-6980

The DHT blocker supplements in that product all look good. These DHT blockers are often used by men with male pattern hair loss, since high DHT is often the primary cause of this type of hair loss.

 

But as you say, you would only need to be concerned about addressing raised DHT if you took creatine on a long term basis.

Hip said: The DHT blocker supplements in that product all look good. These DHT blockers are often used by men with male pattern hair loss, since high DHT is often the primary cause of this type of hair loss.

 

But as you say, you would only need to be concerned about addressing raised DHT if you took creatine on a long term basis.

 

Actually, if it was too much to take regularly, if it at least helped with PEM recovery or certain times when I know I have to do too much, that would be great - I will definitely be trying the creatine hydrochloride a try --

Hip said: List of Supplements Which Reduce PEM

 

PEM Busters for Physical Exertion

 

   • Creatine hydrochloride - 2 grams

   • Citrulline - 1000 mg

   • Branched-chain amino acids (BCAA) - 5 grams

   • Co-enzyme Q10 - 800 mg or higher (this is high dose of Q10)

   • Sodium bicarbonate - ¼ teaspoon (1.5 grams)

   • Catalase - 600 mg (taken after exercise)

   • D-ribose - 5 grams, three times daily

 

Is there any one specific thing that I could try safely and easily? I do use the sodium bicarbonate at times, but wonder which of the other 6 would be worth trialing? And then add another one to it later?

 

Strawberry said: Is there any one specific thing that I could try safely and easily?

Judging by patients' reports, the supplements that have the most potent anti-PEM effects are probably: D-ribose and very high dose Q10. So you could try any one of those.

 

For example, in one patient D-ribose 5 grams x 3 times daily routinely reduces their normal 3 or 4 day PEM down to as little as 12 hours. So that is quite a dramatic improvement.

 

And a single one-off high dose of 2 x 1200 mg of Q10 seemed to virtually eliminate one patient's normal 10 to 14 day PEM, curtailing the PEM within 24 hours. So that is another potent effect.

 

A daily dose of 800 mg of Q10 is reported to raise the PEM threshold (meaning you can do more physical exertion before PEM is triggered). Likewise for creatine: it raised the PEM threshold for one patient, and made any PEM that did appear less severe.

 

You may have to experiment before you find the supplement(s) that suit you.

 

It is possible that some of these supplements may work better as PEM preventers (ie, when taken before exercise/exertion, they raise PEM threshold, and thus help prevent the exercise from triggering PEM).

 

Whereas other supplements may work better when taken once the PEM period has started, where they may help shorten the duration of PEM, or reduce the PEM severity.

 

I started to take Sodium Bicarbonate after physical exercise and that's helped my muscles aching I think.

I believe its the release of lactic acid that it seems to deal with. However, why does mental exertion cause PEM? What substance does mental exertion release that has to be dealt with in the human body?

 

Bansaw said:

However, why does mental exertion cause PEM? What substance does mental exertion release that has to be dealt with in the human body? This is a good question.

 

My theory (briefly outlined in this post) is that it may be the increased brain arousal which results from mental exertion (such as face to face socializing) which then triggers PEM.

 

Thanks for compiling that list Hip.

 

From experience i have to say i do notice positive effects from each supplement you have listed and that's very strange because i'm overly sensitive to most supplements and medication - making me feel restless or overstimulated.

 

Creatine hydrochloride:

In my strength training days i used creatine monohydrate or creatine ethyl ester on and off.

Not sure if it has been debunked or not but back then everyone believed creatine supplementation needed a loadup period of higher intake, a single dose does not work. I usually noticed an increase in strength after a week or so.

 

Citrulline:

This improves my brain fog, doesn't do much for PEM.

 

Branched-chain amino acids (BCAA)

Pre-ME i used BCAA formulas extensively. With BCAA i could add 10 - 15 more minutes to my cardio workout with ease and pump a few extra heavy reps.

 

Co-enzyme Q10

Decreases my PEM if taken the night before.

 

Sodium bicarbonate

I take alka seltzer gold. This very effectively decreases the lactic acid feeling in my muscles.

But somehow it causes constipation, i really like to know why that happens.

 

D-ribose

Does indeed decrease my PEM slightly, but it's derived from corn which i'm allergic to. More than one or two doses daily causes a reaction. If anyone knows of a non-corn derived d-ribose product please let me know.

 

Mental exhaustion / overstimulation is a bigger problem for me than PEM is. I've not really found a solution for that yet. Things that slightly help are high dose fish oil and magnesium malate. I used low dose clonazepam in the past which is very helpful for mental overstimulation but i've stopped using that.

 

Strawberry said:

Is there any one specific thing that I could try safely and easily? I do use the sodium bicarbonate at times, but wonder which of the other 6 would be worth trialing? And then add another one to it later? BCAAs cut my PEM recovery time in half, from 2 days to 1 day. This first happened about a week after starting them. They have not extended my stamina or activity window, but continue to keep my recovery time at about a day. I've been taking them daily for about 2 years now.

 

Bignonia capreolata, a wild vine native to the southeastern US. In the 40’s and 50’s it was a common ornamental in landscaping, even made its way to the Ohio valley and the west coast. I find it in the wild. This year I had a friend harvest, dry, and ship me some. It’s far more common in Appalachia than in my area, I didn’t have the energy to find and process it.

 

I make a tea with it, delicious, an excellent tea. It’s an adaptogen, superior to Ginseng. It tones and promotes proper function of the adrenal glands (adaptogens have many other health benefits). (an excellent book… “Adaptogens – Herbs for Strength, Stamina, and Stress Relief” by David Winston and Steven Maimes) There are lots of adaptogens scattered around the globe. A common adaptogen on Amazon… Ashwagandha.

 

What crossvine (Bignonia capreolata) does for me? It prevents crashes when I over do it in a minor to medium way. I’ll have a bad day or so but not a crash. It helps me recover quicker than without it. A small cup of tea everyday will help for 3 to 5 weeks then the effect weakens. I stop drinking the tea for a couple of weeks then start again.

 

Mary said:

BCAAs cut my PEM recovery time in half, from 2 days to 1 day. This first happened about a week after starting them. They have not extended my stamina or activity window, but continue to keep my recovery time at about a day. I've been taking them daily for about 2 years now.

 

Do you think taking BCAAs daily helps prevent PEM (ie, raises the PEM threshold), or would you say that BCAAs only act to reduce the duration of PEM, once PEM has started?

 

The reason I ask is that if it is only the latter, then you might save some money by only taking the BCAAs once your PEM has begun, just to reduce its duration, assuming that approach works.

 

The same idea may apply to the other PEM busters too: it may be cheaper and easier to take them only once PEM has begun, in order to shorten PEM, rather than taking them all the time.

 

Though if the supplement also has good PEM preventing abilities, then it may be advantageous to take it either all the time, or just on the days that you know you are going to engage in a higher level of exertion.

 

If these supplements mitigate PEM by reducing exercise-induced lactic acid, then it makes sense that you may only need them when you engage in physical exertion (when the lactic acid is generated), and during the PEM period (when the body is trying to clear the lactic acid).

 

Hip said:

Do you think taking BCAAs daily helps prevent PEM (ie, raises the PEM threshold), or would you say that BCAAs only act to reduce the duration of PEM, once PEM has started?

 

The reason I ask is that if it is only the latter, then you might save some money by only taking the BCAAs once your PEM has begun, just to reduce its duration, assuming that approach works.

 

The same idea may apply to the other PEM busters too: it may be cheaper and easier to take them only once PEM has begun, in order to shorten PEM, rather than taking them all the time.

 

Though if the supplement also has good PEM preventing abilities, then it may be advantageous to take it either all the time, or just on the days that you know you are going to engage in a higher level of exertion.

 

If these supplements mitigate PEM by reducing exercise-induced lactic acid, then it makes sense that you may only need them when you engage in physical exertion (when the lactic acid is generated), and during the PEM period (when the body is trying to clear the lactic acid).

 

The BCAAs have not raised my PEM threshold; they only act to reduce the duration of PEM, but it was huge for me. I could try taking the BCAAs only when PEM has begun, instead of all the time, and see what happens, but I'm afraid to do this. Just the thought of going back to a full 2 days or more of recovery is too much for me.

 

I don't think the mechanism of action for BCAAs is reducing exercise-induced lactic acid. Here are some articles about how BCAAs can help and it's not related to lactic acid. I found the first article most interesting:

 

http://www.ncf-net.org/forum/Fword.htm

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=41341 this article has a very interesting paragraph which states:

 

Branch chain amino acids may help CFS patients.

 

If the tryptophan to BCAA ratio is too high, neurotransmitters made from tryptophan increase, causing physical and mental fatigue.4 When patients first contract CF, the body activates a metabolic pathway that increases the rate of conversion of ATP to cyclic AMP, which is used for immune system stimulation. It seems that CF patients have difficulty turning this pathway off when it is no longer required. The inability to properly regulate this pathway leads to losses of ATP in times of inadequate production. Branch chain amino acids can down-regulate this ATP to cyclic AMP process.5

https://www.ncbi.nlm.nih.gov/pubmed/11310928

http://jn.nutrition.org/content/136/2/544S.full

 

@Hip - what first got me looking into BCAAs was my Nutreval testing in 2010 which showed low leucine levels. It wasn't until 4 years later that I googled CFS and leucine and came up with the above research (wish I had done it sooner!)

 

So perhaps a blood test would be a good indicator of who could benefit from BCAAs. I did have a blood test done a year or so to recheck my leucine etc (all the amino acids) and my levels were normal that time, but as I said I'm afraid to stop the BCAAs

 

And I don't know if that blood test was the same as or as accurate as the Nutreval testing.

 

Though I think I could safely cut my dose, I'm still taking almost the full dose and I think I could cut it in half, and actually will give that a try.

 

Mary said:

I don't think the mechanism of action for BCAAs is reducing exercise-induced lactic acid. Here are some articles about how BCAAs can help and it's not related to lactic acid. I found the first article most interesting

 

Yes, I remember reading those articles when you posted them in your BCAA threads. I agree it is certainly possible that BCAAs might reduce PEM by a mechanism other than lactic acid reduction.

 

The theory and mechanism you are referring to is the "central fatigue hypothesis" — the idea that physical exercise-induced central nervous system fatigue (aka: central fatigue, which is the washed out feeling in the mind that athletes get when they train too hard) is driven by serotonin increases in the brain, and that this central fatigue is increased when the free tryptophan / BCAA ratio in the blood increases, because increases in this ratio act to raise serotonin in the brain.

 

So the theory is that by supplementing with BCAA's, you lower this ratio, and thereby reduce serotonin and central fatigue.

 

I just found this article on the subject: Carbohydrates, Branched-Chain Amino Acids and Endurance: the Central Fatigue Hypothesis.

 

At the bottom of this article is says:

Studies on the proposed role of BCAA supplementation are limited, and there are reasons to believe that this approach may not be a viable one.

 

Carbohydrate supplementation, on the other hand, is associated with large decreases in f-TRP and f-TRP/BCAAs, and fatigue is clearly delayed by this nutritional strategy. Note that f-TRP = free tryptophan.

 

So in the article they say that the idea of using BCAAs to reduce central fatigue may not be a viable one.

 

They also note that eating carbohydrates greatly reduces the free tryptophan / BCAA ratio, and greatly reduces fatigue in athletes. So if this central fatigue and free tryptophan / BCAA ratio theory of PEM is right, you would expect PEM to be greatly reduced by switching to high carbohydrate meals or drinks during PEM.

 

That's something ME/CFS patients could certainly try during PEM: test to see if high carbohydrate meals or drinks can reduce the duration or severity PEM.

 

If they can, then it supports your central fatigue and free tryptophan / BCAA ratio theory of PEM. But if such high carbohydrate meals or drinks do not help PEM, then that would suggest that this central fatigue theory of PEM may not be a correct one.

 

In the article, they cite this study on cyclists, which according to the article, found that:

When subjects consumed either the 6% or 12% carbohydrate-electrolyte solutions, the increases in plasma f-TRP were greatly reduced and fatigue was delayed by approximately 1 hr.

 

The carbohydrate feedings caused a slight reduction in plasma BCAAs (~19% and 31% reductions in the 6% and 12% carbohydrate-electrolyte groups, respectively), but this decrease was probably inconsequential with respect to the very large attenuation (fivefold to sevenfold) of plasma f-TRP (20).

 

So that's a major result in reducing fatigue simply by consuming carbohydrates, which greatly reduces free tryptophan in the blood, and greatly reduces the free tryptophan / BCAA ratio.

 

This article also talks about carbohydrates and tryptophan.

 

Basica Active E alkalising mineral formula works well for me.

 

Interesting, @Hip. I don't have the mental wherewithal to properly digest the article you've linked (no pun intended!). Although I'm almost positive that consuming lots of carbohydrates would do nothing for my PEM. It never mattered what I ate or drank, my crashes were depressingly the same.

 

I do know that my PEM duration was cut in half within about 5 days after starting the BCAAs, and has remained at that level ever since. And my leucine was low.

 

So perhaps the BCAAs reduced the PEM duration by a different mechanism (although I don't have a clue what that could be).

 

Where the article states:

 

Studies on the proposed role of BCAA supplementation are limited, and there are reasons to believe that this approach may not be a viable one. I'm not suaded by the fact that studies on BCAAs are limited. Any time I do any research on anything nutrition-related, there's always a caveat that studies are limited - nutritional studies are just limited period. No one's spending tons of money on them as they do on drugs.

 

And when he states that there are reasons to believe that this approach may not be viable, does he give the reasons? I did made an attempt to look at the article but quickly gave up.

 

So I think BCAAs are definitely worth experimenting with. They're non-toxic, affordable, and in my experience at least one would know relatively quickly whether they would be of any benefit. And if they helped someone else as they have helped me, it would be fantastic.

 

Mary said:

So I think BCAAs are definitely worth experimenting with. They're non-toxic, affordable, and in my experience at least one would know relatively quickly whether they would be of any benefit. And if they helped someone else as they have helped me, it would be fantastic.

 

I agree. With these things, the proof of the pudding is in the eating, and if they work for you, that's the bottom line. And if they work, it means the same supplements may also help others with ME/CFS. In fact I have been experimenting with BCAAs on and off ever since I read your threads (though in my case, because I don't get PEM from physical exertion, only from mental exertion, I can't really test any of these PEM busters on myself, except for their effects on mental exertion PEM — but that may be a different sort of PEM).

 

A Post-Exertional Malaise Treatment https://livingwithchronicfatiguesyndrome.wordpress.com

 

I have recently found that sodium bicarbonate (aka baking soda) wards off my post-exertional malaise. I take ¼ to ½ a teaspoon just prior to doing an unavoidable activity that would normally induce a crash. I have so far taken sodium bicarbonate on 6 occasions immediately before tasks such as going to the doctors. In the past, a crash was inevitable however as a result of this treatment, I am yet to crash. The sodium bicarbonate’s mechanism of action may involve causing a reduction of the lactate in my body. Some studies have indicated that this is a property of sodium bicarbonate and that muscles recover faster with this treatment. It is nebulous whether another aspect of sodium bicarbonate is responsible for its effects on me. Several other ME patients have noted a similar effect from this treatment.

 

Hip’s article specifies the rationale behind each ‘crash buster’ including anecdotal reports and studies of possible mechanisms of action. The article is worth reading and can be found here.

 

I am yet to fully explore the scope of the sodium bicarbonate’s benefits and to date will still feel ‘worn out’ after a basic activity however haven’t yet experienced the dreaded crash since taking this new treatment. I also plan to trial some of the other aforementioned ‘pre-activity’ treatments and have creatine hydrochloride lined up to take next. As Clostridium Butyricum can potentially reduce lactate, I should document that my bicarbonate soda experiment did predate my taking of CB by 2 months. I should also note that sodium bicarbonate does have some side effects and hence I have only used it sparingly. I’ve written more extensively about other post-exertional malaise treatments here

 

How to Gain Relief from ‘Post-Exertional Malaise’ https://livingwithchronicfatiguesyndrome.wordpress.com/2010/07/18/how-to-gain-relief-from-post-exertional-malaise

 

Liquorice

 

I first came across using liquorice for crashing by accident. I started to eat some liquorice as I had heard it can help with adrenal fatigue. I was then in a situation in which I would always crash however I did not crash in this instance. Since this event I have used liquorice after I have crashed and it has aided me in recovering from a crash. I have not used it again in helping me avoid a crash as at the time I never anticipate that I will crash. It may however be useful for some people if they know they are going to crash. Some CFS patients may have a worsening of symptoms from trying liquorice. Liquorice should not be used by those with high blood pressure. An article about liquorice for treating CFS (this article is not about crashing) can be found here: http://www.jacemedical.com/store/licorice1.html

 

Liquorice may help me when I am in a crashed state due to its effect in helping the adrenal glands.

 

Other Supplements

 

I have never benefited from any other supplements when in a crashed state. There is anecdotal evidence online regarding some patients having crashing severity and length markedly reduced due to taking supplement such as D-Ribose.

 

Conclusion

 

The term “post-exertional malaise” is a misnomer. It does not accurately describe what I or many other CFS patients experience. A more accurate (albeit slang) term is ‘crashing.’ It is ideal to avoid crashing if possible by planning ahead and setting limits. When I crash, I have been aided by; meditation, warm baths, cold baths, massages and liquorice. There is no universally recognised treatment to aid when one is in a crashed state. These treatments have been effective for me at one time or another but have not alleviated the crashed state. As the mechanisms explaining why CFS patients crash aren’t understood, treatment hasn’t been forthcoming. Some recent research led by Dr Light may be starting to shed some ‘light’ on crashing in CFS patients. The abstract of this study can be found here: http://www.ncbi.nlm.nih.gov/pubmed/20230500 and a summary of this study can be found here: http://www.cfids.org/cfidslink/2009/080503.asp

 

UPDATE: November 2011

 

Some patients report that taking an electrolyte solution such as Hydralyte or Aquaforce improves their crashed status.

A few patients claim that elevating their legs/feet may help ward off an imminent crash. The theory behind this may involve an increased level of blood circulation to the brain. http://www.mecfsforums.com/index.php/topic,9321.0.html

During mid-2011 a paper titled ‘Myalgic Encephalomyelitis: International Consensus Criteria’ was published in the Journal of Internal Medicine by Carruthers et al. Within this criteria, the authors use the term ‘post-exertional neuroimmune exhaustion’ as a synonym for what was previously known by patients as ‘crashing’ or ‘post-exertional malaise.

Update: January 2014

 

I have found frozen Hydralyte iceblocks to be most effective for me when I crash

Update: January 2017

 

I have recently found that sodium bicarbonate (aka baking soda) wards off my post-exertional malaise. I take ¼ to ½ a teaspoon just prior to doing an unavoidable activity that would normally induce a crash. I have so far taken sodium bicarbonate on 6 occasions just prior to tasks such as going to the doctors. In the past, a crash was inevitable however as a result of this treatment, I am yet to crash. The sodium bicarbonate’s mechanism of action may involve causing a reduction of the lactate in my body. Several other patients have noted a similar effect from this treatment.

Hip on Health Rising has written about similar treatments that when taken before exertion may ward off post-exertional malaise. These include:

   • Creatine hydrochloride - 2 grams

   • Citrulline - 1000 mg

   • Branched-chain amino acids (BCAA) - 5 grams

   • CoQ10 800 mg

   • Sodium bicarbonate - ¼ teaspoon (1.5 grams)

   • Catalase - 600 mg (taken after exercise)

   • D-ribose - (5 grams three times daily)

 

Hip’s article specifies the necessary doses of these treatments and the rationale behind each ‘crash buster.’ The article is worth reading and can be found at this website"

 

Crash / Flare Busters For Chronic Fatigue Syndrome and Fibromyalgia https://www.healthrising.org/forums/index.php?resources/crash-flare-busters-for-chronic-fatigue-syndrome-and-fibromyalgia.391

 

 

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