Long COVID: Post-Exertional Malaise (PEM) and Exercise

Long COVID: Post-Exertional Malaise (PEM) and Exercise

Fatigue or extreme tiredness is a common symptom in people with long COVID. You may have a type of fatigue called post-exertional malaise (PEM). It literally means that you don’t feel well- malaise -  following activity.

Although you may not have heard of PEM, you may have experienced it. It is when you have worsening fatigue and/or other symptoms after physical and mental activities - even those requiring little effort. 

PEM is often delayed- i.e. you don’t necessarily feel the effects right after activity, but many hours or even a few days later. 

Along with the extreme fatigue, other long COVID symptoms may worsen (e.g. brain fog (trouble thinking), pain, fever, breathlessness, palpitations (irregular heartbeat), trouble sleeping, etc.


With PEM even seemingly easy tasks, like the list that follows, can cause extreme tiredness that some people describe as a crash.

  • Bathing, dressing, using your phone, or other daily activities

  • Reading mentally challenging articles or books

  • Being late or unprepared increases stress

  • Watching and listening to television impacts your senses

  • Staying in the same body position or overuse of muscles causes fatigue

As you may have realized, PEM causes challenges every day and may be disabling for many.

How Common Is Long COVID PEM?

Post-exertional malaise is very common in those with long COVID.  A worldwide study of the symptoms of over 3700 people with long COVID found almost 3 out of 4 reported PEM.

Cycle Of Fatigue

A repeating cycle, with increasing and ongoing fatigue, called the cycle of fatigue may occur with PEM. It happens when you are active; then have to rest because of the activity; you may feel frustrated because you are unable to do more; after you rest, instead of pacing yourself, you may overdo it/increase activity.

PEM and Exercise

Physical activity and exercise are part of recovery for most conditions - they improve strength, help you sleep, boost your mood, support healing,  prevent complications, etc.  

The same is usually true for people with long COVID, however, those with PEM must be careful. Physical activity and exercise may worsen their fatigue, as well as other symptoms. 

To support their recovery, experts make the following exercise/physical activity recommendations for people with long COVID PEM:

  • Carefully begin exercise therapy. Some people with PEM may not be able to participate in exercise programs

  • Exercise programs should be customized based on the person’s symptoms

  • Increase exercise/activity based on individual response 

  • Check symptoms before, during, and after exercise

  • Pace everyday activities; avoid overdoing it

Goodpath’s Long COVID program

Exercise therapy and activity pacing are part of Goodpath’s long COVID program. Talk with your coach about your PEM symptoms and how physical activity and exercise affect you.