CPET is an objective marker for PEM in ME-patients

Studies on ME-patients using a two-day Cardiopulmonary Exercise Test (CPET) show that the disease is not caused by deconditioning. Measurements on day two versus day one show at anaerobic threshold a reduced oxygen uptake (VO2), reduced work capacity and increased heart rate. At same workload, the lactate concentration increases at day two. Consequently, two-day CPET can be considered as an objective marker for Post Exertional Malaise (PEM) in ME-patients. 

Study references:

1. The Prospects of the Two-Day Cardiopulmonary Exercise Test (CPET) in ME/CFS Patients: A Meta-Analysis. Lim EJ, Kang EB, Jang ES, Son CG. J Clin Med. 2020 Dec 14;9(12):4040. doi: 10.3390/jcm9124040. PMID: 33327624; PMCID: PMC7765094.https://pubmed.ncbi.nlm.nih.gov/33327624/

Conclusion/Main finding: «The overall mean values of all parameters were lower on the 2nd day of the CPET than the 1st in ME/CFS patients, while it increased in the controls. From the meta-analysis, the difference between patients and controls was highly significant at Workload@VT (overall mean: -10.8 at test 1 vs. -33.0 at test 2, p<0.05), which may reflect present the functional impairment associated with PEM.».

2. Comparing Idiopathic Chronic Fatigue and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) in Males: Response to Two-Day Cardiopulmonary Exercise Testing Protocol C. (Linda) M. C. van Campen and Frans C. Visser, Healthcare 2021, 9(6), 683; https://doi.org/10.3390/healthcare9060683 (registering DOI) June 2021 https://www.mdpi.com/2227-9032/9/6/683

Conclusion/Main finding: «This study confirms that male ME/CFS patients have a reduction in exercise capacity in response to a second-day CPET. These results are similar to published results in male ME/CFS populations. Patients diagnosed with ICF show a different response on day 2, more similar to sedentary and healthy controls.». 

3. Deconditioning does not explain orthostatic intolerance in ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) van Campen, C. (Linda) M.C., Rowe, P.C. & Visser, F.C.  J Transl Med 19, 193 (2021). https://doi.org/10.1186/s12967-021-02819-0 https://translational-medicine.biomedcentral.com/articles/10.1186/s12967-021-02819- 0

Conclusion/Main finding: «This study shows that in ME/CFS patients’ orthostatic intolerance is not caused by deconditioning as defined on cardiopulmonary exercise testing. An abnormal high decline in cerebral blood flow during orthostatic stress was present in all ME/CFS patients regardless of their % peak VO2 results on cardiopulmonary exercise testing.». 

4. Insights from Invasive Cardiopulmonary Exercise Testing of Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (not two-day test!) Phillip Joseph, MD, Carlo Arevalo, MD, Rudolf K.F. Oliveira, MD, PhD, Mariana Faria- Urbina, MD, Donna Felsenstein, MD, Anne Louise Oaklander, MD, PhD, David M. Systrom, MD PII: S0012-3692(21)00256-7, DOI: https://doi.org/10.1016/j.chest.2021.01.082

Conclusion/Main finding: «These results identify two types of peripheral neurovascular dysregulation that are biologically plausible contributors to ME/CFS exertional intolerance—depressed Qc [Cardiac output] from impaired venous return, and impaired peripheral oxygen extraction. In patients with small-fiber pathology, neuropathic dysregulation causing microvascular dilation may limit exertion by shunting oxygenated blood from capillary beds and reducing cardiac return.».

5. The Prospects of the Two-Day Cardiopulmonary Exercise Test (CPET) in ME/CFS Patients: A Meta Analysis Eun-Jin Lim, Eun-Bum Kang, Eun-Su Jang and Chang-Gue Son J. Clin. Med. 2020, 9(12), 4040; https://doi.org/10.3390/jcm9124040

Conclusion/Main finding: «The meta-analysis indicates a significant alteration of workload at VT especially on the 2nd day of CPET in ME/CFS patients. Accordingly, the two-day CPET could be considered as one of the potential objective assessment tools for PEM in ME/CFS patients.». 

6. Post-exertional symptoms distinguish Myalgic Encephalomyelitis/Chronic Fatigue Syndrome  subjects from healthy controls Mateo, Lariel J.; Chu, Lily; Stevens, Staci; Stevens, Jared; Snell, Christopher R.; Davenport, Todd;  VanNess, J. Mark Journal: Work, vol. 66, no. 2, pp. 265-275, 2020, DOI: 10.3233/WOR-203168 https://content.iospress.com/articles/work/wor203168

Conclusion/Main finding: «A standardized exertional stimulus produced prolonged, diverse symptoms in ME/CFS subjects. This provides clues to the underlying pathophysiology of ME/CFS, leading to improved diagnosis and treatment.». 

7. Validity of 2-Day Cardiopulmonary Exercise Testing in Male Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, van Campen, C. (Linda) M. C.; Rowe, Peter C.; Visser, Frans C. (2020).  Advances in Physical Education. 10 (01): 68–80. DOI: 10.4236/ape.2020.101007 . ISSN 2164-0386.

Conclusion/Main finding: «The larger sample size of this study improves the confidence with which we can conclude that, like females, males have a similar decrement on day 2 of the consecutive day exercise tests. Our results confirm that 2-day CPET can be used in males to demonstrate the decrease in exercise capacity in research studies and if needed for social security claims. Further comparisons are needed to explore whether the absolute or relative changes in VO2 and workload on day 2 versus day 1 are similar across a wider range of clinical severity, and whether these values differ for subgroups with specific comorbid conditions.». 

8. Two-Day Cardiopulmonary Exercise Testing in Females with a Severe Grade of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Comparison with Patients with Mild and Moderate Disease C (Linda) MC van Campen, Peter C. Rowe, Frans C. Visser Healthcare 2020, 8(3), 192; doi:10.3390/healthcare8030192 https://www.mdpi.com/2227-9032/8/3/192

Conclusion/Main finding: «This is the first study to demonstrate that disease severity negatively influences exercise capacity in female ME/CFS patients. Finally, this study shows that the deterioration in peak workload from day-1 to day-2 is largest in the severe ME/CFS patient group.». 

9. Properties of measurements obtained during cardiopulmonary exercise testing in individuals with myalgic encephalomyelitis/chronic fatigue syndrome. Davenport TE, Stevens SR, Stevens MAJ, Snell CR, Van Ness JM.Work. 2020 Jun 16. doi: 10.3233/WOR-203170. Online ahead of print.PMID: 32568145 https://pubmed.ncbi.nlm.nih.gov/32568145/

Conclusion/Main finding: «CPET measurements demonstrated moderate to high reliability for individuals with ME/CFS. Comparing subjects with ME/CFS and control subjects yielded moderate to large effect sizes on all CPET measurements. MDC95 for all individuals with ME/CFS generally exceeded control subjects and CoVs for CPET measurements were comparable between groups.».

10. A Machine Learning Approach to the Differentiation of Functional Magnetic Resonance Imaging Data of Chronic Fatigue Syndrome (CFS) From a Sedentary Control Destie Provenzano, Stuart D. Washington and James N. Baraniuk Front. Comput. Neurosci., 29 January 2020 https://doi.org/10.3389/fncom.2020.00002 https://www.frontiersin.org/articles/10.3389/fncom.2020.00002/full

Conclusion/Main finding: «The logistic regression model performed on fMRI data significantly differentiated CFS from control with model accuracy of 80.9% on Day 1 before exercise and 76.1% on Day 2 during the period of post-exertional malaise.». 

11. Elevated blood lactate in resting conditions correlate with post-exertional malaise severity in patients with Myalgic encephalomyelitis/Chronic fatigue syndrome Alaa Ghali, Carole Lacout, Maria Ghali, Aline Gury, Anne-Berengere Beucher, Pierre Lozac’h, Christian Lavigne & Geoffrey Urbanski, Sci Rep. 2019 Dec 11;9(1):18817. https://doi.org/10.1038/s41598-019-55473-4https://www.nature.com/articles/s41598-019-55473-4?sfns=mo

Conclusion/Main finding: «ME/CFS patients with elevated blood lactate at rest may be at higher risk for more severe PEM.». 

12. Unexplained exertional intolerance associated with impaired systemic oxygen extraction Melamed KH, Santos M, Oliveira RKF, Urbina MF, Felsenstein D, Opotowsky AR, Waxman AB, Systrom DM. Eur J Appl Physiol. 2019 Sep 6. doi: 10.1007/s00421-019-04222-6. PMID: 31493035.  https://www.ncbi.nlm.nih.gov/pubmed/31493035

Conclusion/Main finding: «We identified a cohort of patients whose exercise limitation is due only to systemic oxygen extraction, due to either an intrinsic abnormality of skeletal muscle mitochondrion, limb muscle microcirculatory dysregulation, or hyperventilation and left shift the oxyhemoglobin dissociation curve.». About the study: https://www.healthrising.org/blog/2019/12/11/oxygen-extraction-post-exertional malaise-chronic-fatigue-syndrome/

13. Reproducibility of Measurements Obtained During Cardiopulmonary Exercise Testing in Individuals With Fatiguing Health Conditions – A Case Series Larson B, Davenport TE, Stevens SR, Stevens J, Van Ness JM, Snell CR Cardiopulmonary Physical Therapy Journal: June 24, 2019 – Volume Publish Ahead of Print – Issue – p doi: 10.1097/CPT.0000000000000100. https://journals.lww.com/cptj/Abstract/2019/10000/Reproducibility_of_Measurements_Obtained_D uring.4.aspx

Conclusion/Main finding: «Nondisabled clients and clients with MS and HIV reproduced or improved in their volume of oxygen consumed (VO2), workload (WL), heart rate (HR), and minute ventilation (VE) at ventilatory anaerobic threshold (VAT) and at peak exercise (except peak WL and VE for the individual with HIV). Neither individual with ME/CFS reproduced VO2, WL, HR, or VE at VAT within literature estimates.».

14. Abnormal blood lactate accumulation during repeated exercise testing in myalgic encephalomyelitis/chronic fatigue syndrome. Lien K, Johansen B, Veierød MB, Haslestad AS, Bøhn SK, Melsom MN, Kardel KR, Iversen PO.  Physiol Rep. 2019 Jun;7(11):e14138. doi: 10.14814/phy2.14138. PMID: 31161646; PMCID: PMC6546966. https://www.ncbi.nlm.nih.gov/pubmed/31161646

Conclusion/Main finding: «In conclusion, previous exercise deteriorates physical performance and increases [Laa] during exercise in patients with ME/CFS while it lowers [Laa] in healthy subjects.».

15. Chronotropic Intolerance: An Overlooked Determinant of Symptoms and Activity Limitation in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome? Davenport TE, Lehnen M, Stevens SR, VanNess JM, Stevens J, Snell CR. Front Pediatr. 2019 Mar 22;7:82. doi: 10.3389/fped.2019.00082. eCollection 2019. Review. PMID: 30968005; PMCID: PMC6439478. https://www.ncbi.nlm.nih.gov/pubmed/30968005

Conclusion/Main finding: «This literature synthesis supports the presence of abnormally blunted HR responses to activity in people with ME/CFS, at both maximal exertion and submaximal VAT.». 

16. Whole blood human transcriptome and virome analysis of ME/CFS patients experiencing post exertional malaise following cardiopulmonary exercise testing. Bouquet J, Li T, Gardy JL, Kang X, Stevens S, Stevens J, VanNess M, Snell C, Potts J, Miller RR, Morshed M, McCabe M, Parker S, Uyaguari M, Tang P, Steiner T, Chan WS, De Souza AM, Mattman A, Patrick DM, Chiu CY. PLoS One. 2019 Mar 21;14(3):e0212193. doi: 10.1371/journal.pone.0212193. eCollection 2019. PMID: 30897114; PMCID: PMC6428308. https://www.ncbi.nlm.nih.gov/pubmed/30897114

Conclusion/Main finding: «Although ME/CFS patients showed significant worsening of symptoms following exercise versus controls, with 8 of 14 ME/CFS patients showing reduced oxygen consumption (VO2) on day 2, transcriptome analysis yielded only 6 differentially expressed gene (DEG) candidates when comparing ME/CFS patients to controls across all time points.». 

17. Diagnostic sensitivity of 2-day cardiopulmonary exercise testing in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Nelson MJ, Buckley JD, Thomson RL, Clark D, Kwiatek R, Davison K. J Transl Med. 2019 Mar 14;17(1):80. doi: 10.1186/s12967-019-1836-0. PMID: 30871578; PMCID: PMC6417168. https://www.ncbi.nlm.nih.gov/pubmed/30871578

Conclusion/Main finding: «The decrease in WR (work rate) at VT (ventilatory threshold) of 6.3-9.8% on the 2nd day of consecutive-day CPET may represent an objective biomarker that can be used to assist with the diagnosis of ME/CFS.». 

18. Cardiopulmonary Exercise Test Methodology for Assessing Exertion Intolerance in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Stevens S, Snell C, Stevens J, Keller B, VanNess JM. Front Pediatr. 2018 Sep 4;6:242. doi: 10.3389/fped.2018.00242. eCollection 2018. PMID:  30234078; PMCID: PMC6131594. https://www.ncbi.nlm.nih.gov/pubmed/30234078

Conclusion/Main finding: «The second CPET measures changes in energy production and physiological function, objectively documenting the effects of post-exertional malaise.». 

19. Physiological measures in participants with chronic fatigue syndrome, multiple sclerosis and healthy controls following repeated exercise: a pilot study. Hodges LD, Nielsen T, Baken D. Clin Physiol Funct Imaging. 2018 Jul;38(4):639-644. doi: 10.1111/cpf.12460. Epub 2017 Aug 7. PMID: 28782878. https://www.ncbi.nlm.nih.gov/pubmed/28782878

Conclusion/Main finding: «These results suggest that exercise exhibits a different physiological response in MS and CFS/ME, demonstrating repeated cardiovascular exercise testing as a valid  measure for differentiating between fatigue conditions.».

20. A Pair of Identical Twins Discordant for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Differ in Physiological Parameters and Gut Microbiome Composition Giloteaux, Ludovic; Hanson, Maureen R.; Keller, Betsy A., American Journal of Case Reports. 17: 720–729. doi:10.12659/AJCR.900314. ISSN 1941-5923. PMC  5058431 Freely accessible. PMID 27721367. (Oct 10, 2016). https://www.amjcaserep.com/abstract/index/idArt/900314

Conclusion/Main finding: «Results suggest dysfunctional immune activation in ILL following exercise and that prokaryotic viruses may contribute to mucosal inflammation and bacterial dysbiosis.  Therefore, a two-day CPET and molecular analyses of blood and microbiomes could provide valuable information about ME/CFS, particularly if applied to a larger cohort of monozygotic twins». 

21. Changes in Gut and Plasma Microbiome following Exercise Challenge in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Shukla SK, Cook D, Meyer J, Vernon SD, Le T, Clevidence D, Robertson CE, Schrodi SJ, Yale S, Frank DN. PLoS One. 2015 Dec 18;10(12):e0145453. doi: 10.1371/journal.pone.0145453. eCollection 2015. PMID: 26683192; PMCID: PMC4684203. https://www.ncbi.nlm.nih.gov/pubmed/26683192

Conclusion/Main finding: «Upon exercise challenge, there were significant changes in the abundance of major bacterial phyla in the gut in ME/CFS patients not observed in healthy controls. In addition, compared to controls clearance of bacteria from the blood was delayed in ME/CFS patients following exercise.». 

22. Inability of myalgic encephalomyelitis/chronic fatigue syndrome patients to reproduce VO₂peak indicates functional impairment. Keller BA, Pryor JL, Giloteaux L. J Transl Med. 2014 Apr 23;12:104. doi: 10.1186/1479-5876-12-104. PMID: 24755065; PMCID: PMC4004422. https://www.ncbi.nlm.nih.gov/pubmed/24755065

Conclusion/Main finding: «ME/CFS participants were unable to reproduce most physiological measures at both maximal and ventilatory threshold intensities during a CPET performed 24 hours after a prior maximal exercise test.». 

23. Decreased oxygen extraction during cardiopulmonary exercise test in patients with chronic fatigue syndrome. Vermeulen RC, Vermeulen van Eck IW. J Transl Med. 2014 Jan 23;12:20. doi:10.1186/1479-5876-12-20. PMID: 24456560; PMCID: PMC3903040. https://www.ncbi.nlm.nih.gov/pubmed/24456560

Conclusion/Main finding: «Low oxygen uptake by muscle cells causes exercise intolerance in a majority of CFS patients, indicating insufficient metabolic adaptation to incremental exercise. The high increase of the cardiac output relative to the increase of oxygen uptake argues against deconditioning as a cause for physical impairment in these patients.». 

24. Discriminative validity of metabolic and workload measurements for identifying people with chronic fatigue syndrome. Snell CR, Stevens SR, Davenport TE, Van Ness JM. Phys Ther. 2013 Nov;93(11):1484-92. doi:10.2522/ptj.20110368. Epub 2013 Jun 27. PMID:  23813081. https://www.ncbi.nlm.nih.gov/pubmed/23813081

Conclusion/Main finding: «Multivariate analysis showed no significant differences between control participants and participants with CFS for test 1. However, for test 2, participants with CFS achieved significantly lower values for oxygen consumption and workload at peak exercise and at the ventilatory or anaerobic threshold. Follow-up classification analysis differentiated between groups with an overall accuracy of 95.1%.».

25. Patients with chronic fatigue syndrome performed worse than controls in a controlled repeated exercise study despite a normal oxidative phosphorylation capacity. Vermeulen RC, Kurk RM, Visser FC, Sluiter W, Scholte HR. J Transl Med. 2010 Oct 11;8:93. doi:10.1186/1479-5876-8-93. PMID: 20937116; PMCID: PMC2964609. https://www.ncbi.nlm.nih.gov/pubmed/20937116

Conclusion/Main finding: «At both exercise tests the patients reached the anaerobic threshold and the maximal exercise at a much lower oxygen consumption than the controls and this worsened in the  second test. This implies an increase of lactate, the product of anaerobic glycolysis, and a decrease of the mitochondrial ATP production in the patients.». 

26. Postexertional malaise in women with chronic fatigue syndrome. VanNess JM, Stevens SR, Bateman L, Stiles TL, Snell CR. J Womens Health (Larchmt). 2010 Feb;19(2):239-44. doi: 10.1089/jwh.2009.1507. PMID:  20095909. https://www.ncbi.nlm.nih.gov/pubmed/20095909

Conclusion/Main finding: «The results of this study suggest that PEM is both a real and an incapacitating condition for women with CFS and that their responses to exercise are distinctively  different from those of sedentary controls.». 

27. Diminished Cardiopulmonary Capacity During Post-Exertional Malaise. Vanness, J. Mark; Snell, Christopher R.; Stevens, Staci R. Journal of Chronic Fatigue Syndrome.14 (2): 77–85. doi:10.1300/j092v14n02_07. ISSN 1057-321. 2007.  https://www.tandfonline.com/doi/abs/10.1300/J092v14n02_07

Conclusion/Main finding: «In the absence of a second exercise test, the lack of any significant differences for the first test would appear to suggest no functional impairment in CFS patients.  However, the results from the second test indicate the presence of a CFS related post-exertional malaise. It might be concluded then that a single exercise test is insufficient to demonstrate functional impairment in CFS patients. A second test may be necessary to document the atypical recovery response and protracted malaise unique to CFS.». 

28. Chronic fatigue syndrome: new evidence for a central fatigue disorder. Georgiades E, Behan WM, Kilduff LP, Hadjicharalambous M, Mackie EE, Wilson J, Ward SA, Pitsiladis YP. Clin Sci (Lond). 2003 Aug;105(2):213-8. doi: 10.1042/CS20020354. PMID: 12708966. https://www.ncbi.nlm.nih.gov/pubmed/12708966

Conclusion/Main finding: « the significant differences between patients with CFS and healthy controls that we observed in several key CNS 5-HT and dopaminergic modulators, assuming that they are indeed reflective of brain 5-HT and dopamine levels, suggest that central neural mechanisms may contribute to the increased perception of effort and impaired exercise tolerance in CFS.». 

Other 

“Post-Exertional Malaise (PEM): Systematic literature search” Norwegian Institute of Public Health, February 2019.

Mapping of research on exertion-triggered illness/worsening of symptoms (Post-Exertional Malaise, PEM) in chronic fatigue syndrome CFS/ME. A systematic literature search has been performed, the references from the search have been reviewed and relevant references have been sorted into different categories. https://www.fhi.no/en/publ/2019/Post-Exertional-Malaise-PEM/ (Report in Norwegian only). 

Videos and webinars that describes exercise tests and explains PEM 

• David M. Systrom, MD, Director of the Massachusetts General Hospital Cardiopulmonary laboratory, Boston, Massachusetts. Assistant Professor of Medicine at Harvard Medical School “Pathophysiology of Exercise Intolerance in Chronic Fatigue Syndrome” 24 October, 2020 https://youtu.be/TyQpilazB_E

• Professor Christopher R. Snell, Pacific Fatigue Laboratory, Calefornia, USA, “ME/CFS, CPET, PEM, COVID, GET and more” 28. august, 2020: https://m.youtube.com/watch?v=2fJt14pJymw

• David M. Systrom, MD, Director of the Massachusetts General Hospital Cardiopulmonary laboratory,  Boston, Massachusetts. Assistant Professor of Medicine at Harvard Medical School “Pathophysiology of Exercise Intolerance in Chronic Fatigue Syndrome” May 5th, 2020 https://youtu.be/Q335NFTSZno

• Staci Stevens, Todd Davenport and Mark VanNess. “Why Working out Doesn’t Work. Answers from 20 years of cardiopulmonary exercise testing (CPET) in ME/CFS” December 18th, 2019, https://vimeo.com/380338703

• Professor Betsy Keller, PhD, Ithaca College, New York “PEM – ergospirometry testing and coping strategies to avoid PEM”, December 8th, 2019 (Norwegian subtitles). https://youtu.be/nzY_7Z-eUcA

• Staci Stevens, Dr. Chris Snell, Mark VanNess, Brian Hughes, Jonathan Edwards “Understanding Graded Exercise Therapy for ME/CFS” – built on a false premise” November 1st, 2019, https://www.dialogues-mecfs.co.uk/films/graded-exercise-therapy/

• David M. Systrom, MD, Director of the Massachusetts General Hospital Cardiopulmonary laboratory, Boston, Massachusetts. Assistant Professor of Medicine at Harvard Medical School “Pathophysiology and treatment of exertional intolerance in ME/CFS: insights from cardiopulmonary exercise testing” April 4th, 2019, https://youtu.be/1emsA2CcRK4?t=17636

• Katarina Lien, MD and PhD student, University of Oslo “Post Exertional Malaise in ME/CFS patients” January 14th, 2019 (English subtitle) https://youtu.be/ol96vxqJ8rA

• David M. Systrom, MD, Director of the Massachusetts General Hospital Cardiopulmonary laboratory, Boston, Massachusetts. Assistant Professor of Medicine at Harvard Medical School “Advancements in ME/CFS Research”, David M. Systrom, MD; Brigham and Women’s Hospital | ME/CFSAlert 98” July 2nd, 2018, https://m.youtube.com/watch?feature=youtu.be&v=FMaKfv8peww

• Dr. Peter Rowe, professor in paediatrics, John Hopkins hospital, USA, “Inducing Post Exertional Malaise: A look at the research evidence” July 16th, 2015 https://youtu.be/ux93w7yGQ5g

• Dr. Lily Chu, Stanford University, USA, “Post Exertional Malaise: History, Characteristics, Evidence” June 23rd, 2015, https://youtu.be/hxJPrkWHcBo

• Professor Christopher R. Snell, Pacific Fatigue Laboratory, California, USA, “Making the case for clinical exercise testing in CFS/ME research and treatment” Sept. 23rd, 2012, https://m.youtube.com/watch?v=nL49DwGRs30&t=1s

• Staci Stevens, MA in exercise physiology. Director of the Pacific Fatigue Lab, Founder and Director of  Workwell Foundation, Ripon, California, USA, “MECFS Alert Episode 32“, August 6th, 2012, https://m.youtube.com/watch?feature=youtu.be&v=kCO3pAbSq3I

Patient experiences 

• Interview with psychologist specialist and former professional cyclist Ingunn Ullerhaug  EKKO, NRK Radio June 6th, 2019 (Norwegian speech only) https://radio.nrk.no/serie/ekko/MDSP25011219/06-06-2019#t=21m40.08s

• «From Tour de France to ME» Chronicle by psychologist specialist and former professional cyclist Ingunn Ullerhaug, NRK, June 6th, 2019 (Norwegian text) https://www.nrk.no/ytring/fra-tour-de-france-til-me-1.14611826

Written by

Jørn Tore Haugen  

Master of Science in Engineering

3 tanker på “CPET is an objective marker for PEM in ME-patients

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