Episode 149: Not all Post-Exertional Malaise (PEM) is the same

Not all post-exertional malaise (PEM) is driven by the same physiology — and understanding the difference can completely change how you approach pacing and recovery. In this episode, Anna breaks down the three most common patterns of post-exertional crashes seen in clinical practice: autonomic “hit the wall” crashes, metabolic “wired but exhausted” responses, and delayed immune-driven flares. You’ll learn why timing matters, how different symptom patterns reflect different underlying mechanisms, and why applying the wrong strategy can stall progress. This is not about avoiding movement or labelling yourself as fragile. It’s about understanding your physiology well enough to work with it. If you’ve ever felt confused by your crashes — or wondered why generic pacing advice hasn’t quite worked for you — this episode will offer clarity. Complimentary Episode: Episode 146: Research Review - The PEM puzzle Resources Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/

We’re back again this week sharing a recording from one of our Nurturing Resilience Group Calls. Each month we have one call dedicated to the nervous system and one call dedicated to what I call the more “practical” elements of recovery. In this recording you will hear some of our members asking their questions and we cover topics such as protein consumption, building up physical capacity and endurance, rehabilitation for deconditioning that happens when you have been ill a long time, migraines, delayed recovery after infections, what to do when you have more energy and how to manage guilt around not “doing enough”. This is a varied conversation that covers a range of useful topics. If you want to take part yourself, you are very welcome to join the Membership and get involved.  Join Nurturing Resilience: https://annamarsh.co.uk/nurturing-resilience/ Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/

This week on the podcast we do something a little different. We share a recording from the Nurturing Resilience Membership where we focus on supporting your Nervous System as you navigate recovering from Chronic Fatigue and other Energy Limiting Illness. This is your opportunity to be a fly on the wall of one of our group calls and if you want to take part yourself, you are very welcome to join the Membership and get involved. We cover topics such as using yin yoga for emotional processing, discharging survival energy, finding purpose in life while navigating recovery and how to create stability as you navigate the inevitable ups and downs.  Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/

Post-exertional malaise (PEM) is more than just feeling tired after activity — it’s a delayed and often severe worsening of symptoms that affects many people with ME/CFS and other energy-limiting conditions. In this episode, Anna unpacks what PEM is, why it happens, and what current research is beginning to reveal. Anna explains how PEM differs from everyday fatigue, explores emerging insights into energy production, inflammation, and stress responses, and discusses why “pushing through” can be harmful. She also reflects on what this research means in real life, and how it can support safer pacing, validation, and more compassionate approaches to recovery. This episode is a helpful listen if you want to better understand PEM, feel more validated in your experience, or learn how research can guide gentler, more supportive ways of managing energy. Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/ Article Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC12408823/

Oxaloacetate is a compound that plays an important role in cellular energy production and mitochondrial function. In this episode, Anna explores the emerging interest in oxaloacetate as a potential support for people with Chronic Fatigue and other energy-limiting conditions. Anna explains what oxaloacetate is, why it has gained attention in the chronic fatigue space, and how it may influence metabolism, inflammation, and energy production. She also discusses who may benefit, important considerations around dosing and sensitivity, and where oxaloacetate fits within a broader, foundations-first approach to recovery. This episode is a helpful listen if you’re curious about oxaloacetate, considering supplementation, or wanting to understand how targeted interventions can support energy when used thoughtfully and in the right context. Supplement: https://uk.iherb.com/pr/advanced-orthomolecular-research-aor-benagene-30-capsules/3308 Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/

We’ve all been there. You share some details about your chronic illness with a friend, family member or colleague and instead of empathy, you receive a prescription for yoga, meditation or a B12 injection. Although the unsolicited advice is well meaning, often it can be another load that we have to manage. Chronic illness is complex and nuanced and it is exhausting to explain the physiological complexity as well as the dramatic impact it is having on your life. This episode is here to help you waste less energy with some ideas about how you can respond in situations of unsolicited advice or when someone challenges how you are caring for your health.  Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/

Mistakes are how we learn and grow and the same is true for Chronic Fatigue Recovery. In this episode Anna shares what she wouldn’t do if she had to recover from Chronic Fatigue all over again. She shares lessons and learnings from her own experience and experience working with clients. She weaves in guidance on what she would do instead so that you can learn to build strong health foundations from the ground up.  Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/

Cycle syncing is a practice whereby you align your diet, lifestyle and energy management around your menstrual cycle. In this episode Anna answers the question: can this be helpful if you have Chronic Fatigue? Anna gives an overview of the menstrual cycle and explains how imbalances at certain points in the cycle can make us feel a certain way. She shares her own experience with cyclical fluctuations in energy and how she managed them, things that have worked clients and how to manage your cycle if you have histamine intolerance or MCAS.  Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/ Additional Resources: How to have better periods, Part 1 How to have better periods, Part 2 How to have better periods, Part 3 Perimenopause

Prompted by a question from a Nurturing Resilience Member, Anna answers the question about how long to keep going with things when you aren’t seeing progress. She talks about the importance of laying life long foundations, getting overwhelmed by healing gadgets, supplement grave yards, the importance of context, strategy and structure, testing and retesting and how giving yourself a break can be the best thing at times! Useful Links Take the Chronic Fatigue Quiz: https://app.annamarsh.co.uk/quiz-page Instagram: https://www.instagram.com/anna__marsh_ Work with me: https://annamarsh.co.uk/work-together/ Website: http://annamarsh.co.uk/ Join the Nurturing Resilience Subscription: https://annamarsh.co.uk/nurturing-resilience/ Healing On A Budget Episode: https://annamarsh.co.uk/podcast/healing-on-a-budget/

***PLEASE NOTE*** Prices quote in this episode have increased since recording AND we have also added a selection of Pay As You Go Services to help people manage their budgets. Each week I get enquiries from people who are experiencing energy limiting conditions such as CFS/ME, Long Covid, Post Viral Fatigue and Mould Illness. Your health is the most important thing and you want to make sure that whoever you work with is the right fit for your needs and your budget. Which is why I wanted to create a podcast episode where I talk about how I work and the different options - to help you decide if it could be the right thing for you. In this episode I cover my qualifications, scope of practice and break down the different ways I work with clients in my business. If you have been thinking about working with a practitioner to support your health and are considering working with me, this episode is for you.  Useful Links 6 Month Package: https://annamarsh.co.uk/1-1/ Road Map: https://annamarsh.co.uk/fatigue-recovery-roadmap/ Nurturing Resilience Membership: https://annamarsh.co.uk/nurturing-resilience/ Pay as You Go Services: https://go.annamarsh.co.uk/booking/anna-marsh-services