Energy Envelope Theory: Positive Evidence Supporting Pacing
Evidence Against GET and CBT
Most of the argument for pacing is actually made with evidence against graded exercise therapy and curative cognitive behavioral therapy. A 2019 survey by NICE found that 85.9% of patients prescribed GET experienced worsened pain, muscle, brain fog, health, mental health, symptoms, cognitive health, malaise and fatigue.
It does stand to reason that if GET and curative CBT are harmful that the opposite of that would be beneficial and the opposite of GET & CBT is not increasing activity and accepting illness limitations in other words, pacing.
But this post will go beyond this argument for pacing and examine studies which actually evaluate the value of specific levels of available energy usage.
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Energy Envelope Theory
The Energy Envelope Theory posits that each person with ME/CFS has a set envelope of energy each day and by using as close to this amount of energy as possible each day a patient may be able to increase the size of their energy envelope over time.
The Energy Envelope Theory is based on the observation that when patients with ME/CFS overexert they cause post-exertional malaise (PEM) that makes their illness worse. Thus the theory assumes the converse also applies and if patients do not overexert their illness will get better.
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Studying The Energy Envelope
In order to study the energy envelope patients are asked to rate their available energy at the start of the day from 1 to 100 and to rate how much energy they used from 1 to 100. If someone used less energy than they perceived available they "underexerted" if the ratio was close to 1 they "balanced" and if they used more than they perceived they had they "overexerted."
This method produces not only a metric for whether people exceed their envelope but also for how much they have exceeded their envelope. Note that it does break down if the available energy gets too close to zero as it will then produce exceedingly large numbers for overexertion by even a few percentage points.
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Staying Inside The Energy Envelope Works
Early studies of the Energy Envelope included a 16-week case study where the participant's reduction in energy usage led to increased energy and decreased fatigue and a 3-participant study where a buddy system was used to reduce energy expenditure which led to reductions in fatigue and bodily symptoms.
A much larger study, Jason et all 2008, studied 110 individuals with ME/CFS and found overexertion was associated with increased disability, pain, fatigue, depression, anxiety, disordered sleep, and lowered quality of life. A 2013 follow-up confirmed these results.
Additionally, a study by Taylor et all that studied the effect of educating patients on conservation of energy including the energy envelope theory found overall significant increase in the self-esteem, well-being, mastery, work, energy, and interpersonal relationships of patients who received this education in comparison to controls.
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Severity & Energy Envelopes
A 2017 study examined the relationship between functioning groups and energy envelopes. This study broke down participants by whether they had high or low daily perceived energy and by whether they were over or under-exerting.
The study found that low-energy participants benefitted more from under-exertion and high-energy participants suffered more from overexertion.
In other words "aggressive resting" or underexertion benefits severe patients more but the danger of overexertion is greater in mild patients.
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Limits Of The Energy Envelope Studies
While the Energy Envelope Theory states that by staying inside the energy envelope patients can expect to increase the size of their energy envelope overtime, no studies have shown a correlation between staying within the envelope and long term increases in functioning. In other words pacing does not as the theory posits consistently lead to improvement in illness severity.
Rather the majority of documented positive effects are in regards to symptoms and functioning in the 24 hours following energy management.
However, while no studies have confirmed following the energy envelope theory to lead to remission, this does not mean pacing does not have long-term benefits. It simply means that pacing is only supported as a symptom-based treatment, not a curative treatment.
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Summary
The Energy Envelope Theory says that every person with ME/CFS has a set amount of energy to use each day and if they do not use more than that amount they can improve their illness over time.
The Energy Envelope Theory is studied by asking people whether they use more or less energy each day than they feel they had available.
Studies of the Energy Envelope Theory found that:
-Staying within the Energy Envelope improves symptoms and quality of life
-For severe patients, there is an additional benefit to underexerting
-For mild patients, there is greater harm from overexerting
Insufficient evidence exists to show whether staying within the energy envelope for extended periods of time will lead to recovery.
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Sources
2019 NICE Survey On GET & CBT
2013 Jason et All Provision Of Social Support to Individuals with Chronic Fatigue Syndrome aka "Buddy System Study"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693568/
1997 16 Week Case Study
King CP, Jason LA, Frankenberry EL, et al. Think inside the envelope. CFIDS Chron. 1997;10:10–14
2008 Jason et All Energy Envelopes Study
https://journals.sagepub.com/doi/abs/10.1177/216507990805600502
2006 Taylor et All Energy Conservation Education Study
Taylor RR, Jason LA, Shiraishi Y, et al. Conservation of resources theory, perceived stress, and chronic fatigue syndrome: outcomes of a consumer-driven rehabilitation program. Rehabil Psychol. 2006;51:157–165
2013 Jason et All Energy Envelopes Study
https://www.tandfonline.com/doi/abs/10.1080/21641846.2012.733602
2017 O'Connor et All Energy Envelopes Study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750135/
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Pacing is the only evidence-based treatment for Myalgic Encephalomyelitis, particularly the defining symptom of (PENE) Post Exertional Neuroimmune Exhaustion / (PEM) Post Exertional Malaise
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A common way to explain pacing is that one must stay within their Energy Envelope like a budget of how much energy you can use each day.
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But the energy envelope is more than just a metaphor, the Energy Envelope Theory is one of the ways by which we have studied pacing and proven it to be effective. Studies of the energy envelope are the reason we can say that pacing is an evidence-based treatment.
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While Graded Excercise Therapy (GET) has been proven harmful by studies and surveys such as the 2019 NICE Survey showing an 85% rate of increased symptoms, this alone does not prove that pacing is helpful. Only that pushing is harmful.
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Studies of the energy envelope have revealed that pacing not only prevents the harm that pushing through symptoms causes, learning about and following an energy envelope approach to pacing also leads to improvements in
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-Depression
☆Symptoms
☆Quality of Life
-Fatigue
-Pain
☆Personal Relationships
and more...
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There are many ways of pacing, all have their benefits. But the energy envelope is by far the best studied. This is because it is both a practical method for tracking energy usage and a theoretical device for conceptualizing pacing within research.
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So how can you replicate the energy envelope method of pacing at home?
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1. Rate how much energy you feel you have available from 0 to 100 in the morning
2. Each day try to use only your available energy. If you have severe ME aim to use less than you have available (underexertion).
3. At the end of the day rate how much energy you feel you used.
4. Keep track of your progress by finding the ratio of energy used to energy available. Aim to keep this ratio close to 1 or below 1 if severe.
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Of course, other methods of pacing such as hr monitoring, using timers, the traffic light system etc may be better suited to some.
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Happy pacing!
