Lifestyle modifications


  • The “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 activities throught the day. If more energy is spent the symptoms may worsen. The envelope size may vary from day to day (1).
  • Pacing or activity management strategies may prevent and reduce worsening of symptoms among CFS/ME patients. 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) and 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 adaptation of appropriate coping and management of CFS/ME (1)


  • Observing nature, listening to music and similar activities may improve wellbeing and reduce distress, perception of fatigue, anxiety and depression (1).
  • Cognitive strategies and coping skills to reduce negative emotions 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).






Figure: Evidence pyramid

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

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

​Evidence based on randomized controlled trials is written in PLAIN font

Evidence based on observational / cohort studies is written in CURSIVE font