Muscle Changes - PEM Post-Exertional Malaise (PEM) - Disaster Management
Research on Long Covid and Its Impact on Muscle Tissue and the Increase of Post-Exertional Malaise (PEM)
Professor Dr. Rob Wüst (Vrije Universität Amsterdam, Netherlands) has investigated how Long Covid damages muscle tissue and contributes to post-exertional malaise (PEM). In 2022, Dr. Wüst received a Solve Ramsay Research Grant to study muscle dysregulation and PEM in patients with infection-associated chronic conditions. Recently, he published a review article (3) in the journal Trends in Endocrinology and Metabolism, explaining how changes in the muscle tissue of Long Covid patients are related to PEM. He has developed a comprehensive approach to researching the effects of Long Covid and ME/CFS on muscle tissue. (1)
Here are the key findings summarized (read in detail here)
Dysregulation of Muscle Tissue
- Muscles of Long Covid patients show unusual mitochondria in size and position, as well as reduced cellular respiration.
- Muscle atrophy and changes in muscle fiber composition, especially a decline in type 1 fibers that prevent fatigue.
Changes in Blood Vessels
- Thickening, constriction or damage of blood vessels in the muscles, leading to inadequate oxygen and nutrient supply as well as insufficient removal of waste products.
Post-Exertional Malaise (PEM)
- These changes worsen with PEM, further reducing the physical performance of patients.
Hypotheses on the Cause
- Misguided immune reactions attacking important parts of muscle tissue or blood vessels.
- Central fatigue, where the central nervous system improperly regulates muscle contractions.
- Reduced physical activity of patients, although this does not explain all muscle changes.
Connection to ME/CFS
- Many of the observed muscle changes and PEM also affect patients with ME/CFS.
- PEM is typical for ME/CFS and is a diagnostic criterion.
Current and Planned Treatments
- Currently, there are no FDA-approved medications to reduce PEM in Long Covid.
- Various clinical studies are evaluating treatments such as immunoadsorption, dietary supplements, hyperbaric oxygen therapy, anti-inflammatory and antiviral medications.
Why chronic exercise intolerance (PEM) must be taken into account in crisis planning
Now you may be asking yourself: What does this have to do with disaster management? In my opinion – unfortunately, a great deal.
Recent research findings by Dr. Rob Wüst show how long COVID and post-exertional malaise (PEM) affect muscle tissue and profoundly restrict the lives of those affected. The resulting physical and neurological limitations not only impact the healthcare system, but also have direct relevance for disaster preparedness, emergency response planning, and infrastructure management.
Why disaster management is affected
❗ Reduced operational capacity of emergency services personnel with long COVID/PEM
❗ Increasing demand for specialized long-term care, including in crisis regions
❗ Need for resilient structures for chronically ill people
❗ Increased psychological stress due to chronic symptoms in uncertain times
❗ Challenge of reintegrating those affected after disasters
Scenario 1
Disaster relief & emergency services – When long COVID & PEM slow down response times
Impact
Emergency personnel suffering from long COVID and experiencing post-exertional malaise (PEM) may have severely limited physical capacity, often permanently. This has serious consequences:
- Reduced availability of qualified personnel in critical situations
- Higher absenteeism due to inability to tolerate physical or mental exertion
- Risk of misdiagnosis or excessive demands on the ground if symptoms are not recognized
There is an urgent need
- Training programs for emergency personnel and management staff on the recognition and management of PEM and Long Covid
- Provision of basic medical knowledge and self-regulation strategies for those affected while on duty
- Adjustment of physical stress limits in operational planning
Consequences & action strategies
Differentiated strategies are needed to maintain operational readiness and minimize the burden on those affected:
Resource mobilization
Mobilization of alternative resources such as reserve teams, e.g., trained volunteers, retired emergency personnel, international aid organizations with special expertise
Adaptation of deployment and standby plans
- Expansion of standby models with sufficient replacement personnel
- Introduction of job-sharing models for physically impaired emergency personnel
- Shorter shifts and flexible working hours to avoid peak loads
Possible consequences
- Increased operational costs due to additional staff shifts and training
- Delayed response times if adequate replacement personnel are not provided
- Long-term effects on the crisis resilience of the overall system if health restrictions are not taken into account
Scenario 2
Long-Term Healthcare in Disaster Zones – Challenges Posed by PEM & Long Covid
Impact
Medical care during disasters is often limited — strained infrastructure, staff shortages, and urgent triage. For individuals affected by Long Covid or post-exertional malaise (PEM), this situation becomes even more critical:
- Chronic illnesses like PEM require continuous, specialized support, which is rarely available during crises
- In disaster zones, there may be a lack of qualified personnel, essential medications, or quiet recovery spaces
- Emergency shelter environments often fail to accommodate PEM-specific needs, such as low-stimulation zones or extended rest
- Even minimal exertion can trigger severe symptom relapses, making standard emergency support insufficient
Strategic Responses & Recommendations
Specialized Medical Teams
- Deploy mobile medical units with expertise in PEM, ME/CFS, and Long Covid
- Responsibilities include patient stabilization, treatment planning, and symptom monitoring in disaster settings
Telehealth & Digital Tools
- Implement telemedicine systems, including satellite-based communications if needed
- Use AI-assisted tools to evaluate fatigue levels, manage medication, and flag early warning signs
Psychosocial Support Networks
- Establish remote counseling services and peer-based support groups, accessible even during infrastructure breakdowns
- Provide self-help resources tailored to PEM/Long Covid patients in crisis situations
Resource Management
- Ensure adequate stocks of medications and assistive equipment for PEM/Long Covid treatment
- Equip shelters with accessibility checklists: low-noise zones, sensory-friendly environments, dietary modifications
Implications for Disaster Management Planning
- Increased need for interdisciplinary crisis response teams with chronic care expertise
- Emergency infrastructures must be adapted to support PEM-compatible conditions
- Long-term care must be integrated into recovery and rehabilitation strategies — not just acute crisis response
- Including people with chronic illness in disaster planning fosters systemic resilience and inclusive recovery
Scenario 3
Return to Normality – PEM and the Challenges of Post-Disaster Recovery
Impact
Affected persons affected by post-exertional malaise (PEM) or Long Covid often face significant obstacles when trying to return to their normal routines after a disaster. This doesn't only hinder individual recovery — it also affects broader reconstruction efforts:
- Severe limitations in mobility, stamina, and cognitive focus
- Slow or incomplete reintegration into work, education, and social life
- Increased psychological strain due to ongoing symptoms and lack of recovery prospects
- Lack of infrastructure designed to support chronic illness during transition phases
Strategic Measures & Approaches
Individual Support
- Provide adjusted working conditions, such as flexible hours, part-time options, or remote work
- Ensure access to psychosocial support programs for emotional stability and self-management
- Develop customized rehabilitation plans tailored to PEM/Long Covid recovery patterns
Infrastructure & Accessibility
- Incorporate barrier-free design principles into post-disaster reconstruction
- Ensure the availability of low-stimulation areas and rest zones in temporary shelters
- Guarantee continued access to specialized medical care and follow-up services
Social & Financial Assistance
- Implement financial aid programs to compensate for reduced work capacity
- Provide long-term reintegration services for employment, education, and independent living
- Establish monitoring mechanisms to track health development and respond to relapses early
Implications for Disaster Management
- Recovery plans must go beyond infrastructure and actively support the well-being and re-entry of chronically ill individuals
- Emergency and recovery strategies must become inclusive and adaptable to diverse health profiles
- Chronic health conditions must be viewed as a core element of community resilience
Scenario 4
Strengthening Societal Resilience – Preventing Chronic Illness Through Crisis Preparedness
Impact
The increasing frequency of disasters — such as pandemics, heatwaves, and floods — not only presents acute hazards but also contributes to a rise in chronic health conditions over time. Millions are now affected by Long Covid, PEM, MCS, and ME/CFS, often triggered or worsened by poorly managed crises.
- Chronic illness is not just an individual burden – it has system-wide implications for public health and workforce readiness
- People with physical vulnerabilities are especially at risk during emergencies
- A lack of prevention leads to greater absenteeism in essential roles and undermines the resilience of communities and health systems
Preventive Strategies and Measures
Health Promotion and Resilience Building
- Launch public health campaigns to promote physical baseline fitness and stress tolerance
- Educate communities about post-infection pacing and prevention of long-term complications
- Encourage healthy lifestyles: movement, balanced nutrition, quality sleep, and environmental awareness
Awareness & Capacity Building
- Integrate health literacy and self-care strategies into school and vocational education
- Embed climate-linked health risks into civil protection and risk communication
- Raise public understanding of invisible conditions like PEM to reduce stigma and misinformation
Policy and Infrastructure
- Support health-oriented urban planning: green spaces, cooling zones, low-emission areas
- Strengthen public healthcare systems with monitoring programs for post-viral syndromes
- Invest in interdisciplinary research into mechanisms and prevention of chronic illness
Relevance to Disaster Management
- Crisis preparedness must account for long-term public health outcomes, not just short-term response
- Promoting physical resilience reduces the long-term impact of future disasters
- Societal resilience begins with prevention – far before the next crisis emerges
Szenario 5
Research & Development – Innovation as a Key to Resilience
Impact
Research findings, such as those from Dr. Rob Wüst, could accelerate the development of new treatments and therapies for PEM, which in turn could improve the efficiency and effectiveness of disaster management.
- Currently, there are no FDA-approved medications specifically for reducing PEM in Long Covid
- Existing research remains too fragmented to develop targeted clinical treatments
- Chronic impairments among key workers, responders, and affected populations weaken emergency capacity over time
Strategic Opportunities
Strengthening Cross-Sector Collaboration
- Foster cooperation between researchers, clinicians, and disaster response professionals
- Encourage joint projects focusing on PEM and Long Covid treatment innovations
- Build institutional alliances to improve symptom recognition and crisis-specific care protocols
Supporting Clinical Research
Provide funding for trials testing
- Immunoadsorption therapies
- Nutritional supplements and micronutrients
- Hyperbaric oxygen therapy
- Anti-inflammatory and antiviral treatments
- Prioritize longitudinal studies with practical application in disaster scenarios
Technological Advancement
Leverage AI and machine learning to
- Analyze large-scale patient data
- Predict symptom trajectories
- Design personalized treatment models
- Use wearable devices and biosensors for real-time fatigue tracking and pacing optimization
Translating Research into Practice
- Ensure effective knowledge transfer between research centers and field professionals
- Offer regular training and continuing education for emergency responders on PEM, ME/CFS, and Long Covid management
- Develop practical implementation guides to integrate scientific findings into disaster protocols
Research as a Resilience Engine: We must view applied research as an active part of resilience planning. By supporting innovation, bridging disciplines, and translating science into operational knowledge, we lay the groundwork for more sustainable, inclusive, and health-centered disaster response strategies.
These scenarios are intended to illustrate how Dr. Wüst's research findings could impact disaster management and what measures could be taken to mitigate the effects of Long Covid, ME/CFS and PEM. And we should not forget that there are plenty of similar cases where chronic illnesses can lead to post-exertional malaise (PEM), meaning the pool of affected individuals is significantly enlarged.
Chronic Illnesses Involving PEM – A Broader Scope of Affected Populations
PEM is not unique to Long Covid. It’s a shared symptom across multiple chronic conditions, widening the field of those who must be considered in health and crisis planning.
Conditions Commonly Associated with PEM
1. People with rare muscle diseases such as centronuclear myopathies (CNM).
2. PEM is a common symptom of CFS and leads to a significant worsening of symptoms after physical or mental exertion. (2)
3. Post-polio syndrome occurs in people who have survived polio and develop symptoms such as muscle weakness, pain, and fatigue years later. Similar to Long Covid and CFS, PPS can also cause PEM, severely limiting the ability of affected individuals to engage in physical activities. (2)
4. Chronic Lyme disease is a long-term infection caused by the bacterium Borrelia burgdorferi. PEM is also a common symptom and can significantly impair the quality of life of affected individuals.
5. Systemic lupus erythematosus is an autoimmune disease that can attack various organs and tissues in the body. Affected individuals can experience chronic fatigue and post-exertional malaise, which impairs their ability to participate in daily activities. (2)
This contribution was written by Birgit Bortoluzzi, the creative founder of the “University of Hope” – an independent knowledge platform with a mission: to make resilience, education, and compassion visible and audible in a complex world.
Source References
(1) Solve Long COVID Initiative Solve-funded researcher reviews how Long COVID changes muscle tissues to increase post-exertional malaise (PEM). Available at: https://solvecfs.org/solve-funded-researcher-reviews-how-long-covid-changes-muscle-tissues-to-increase-post-exertional-malaise-pem/ (Retrieved: January 27, 2025)
(2) SpringerLink – Journal of Clinical and Experimental Medicine Long COVID: The role of skeletal muscle in post-exertional malaise (PEM). DOI: 10.1007/s41906-023-2553-0 https://.link.springer.com/article/10.1007/s41906-023-2553-0 (Retrieved: January 27, 2025
(3) Charlton, B. T. et al. (2024) Skeletal muscle adaptations and post-exertional malaise in Long COVID. Open access, published December 17, 2024. Authors: Braeden T. Charlton¹², Richie P. Goulding¹², Richard T. Jaspers¹², Brent Appelman³⁴, Michèle van Vugt⁴⁵, Rob C. I. Wüst¹² (Retrieved: January 27, 2025) – ¹² Vrije Universiteit Amsterdam / Amsterdam UMC – ³⁴ Erasmus MC – ⁴⁵ Amsterdam Institute for Global Health and Development / Amsterdam UMC Skeletal muscle adaptations and post-exertional malaise in long COVID December 17, 2024, Open access (Braeden T. Charlton1,2 ∙ Richie P. Goulding1,2 ∙ Richard T. Jaspers1,2 ∙ Brent Appelman3,4 ∙ Michèle van Vugt4,5 ∙ Rob C.I. Wüst1,2)