#26 The truth about exercise & pacing in ME/CFS, Long Covid & POTS, with Todd Davenport

8 snips

Jan 23, 2026

Todd Davenport, physiotherapist and exercise scientist who studies ME/CFS, Long Covid and post-exertional neuroimmune exhaustion. He explains why traditional exercise can trigger post-exertional symptom exacerbation. Two-day CPET findings and impaired oxygen use are explored. Heart-rate–based pacing, estimating thresholds without CPET, and how individualized activity management can prevent crashes and slowly improve baseline.

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ANECDOTE

Going For A Run Can Trigger Relapse

Many patients try a run or gym session when partially recovered and report becoming sicker than before.
Emily Kate Stephens and others described feeling as if they "had COVID again" after such exertion.

INSIGHT

Two-Day CPET Shows Day-Two Oxygen Drop

Two-day CPET reveals a lowered ventilatory anaerobic threshold on day two in ME/CFS and Long Covid patients.
This shows reduced oxygen utilization and earlier fatigue at lower workloads compared to controls.

INSIGHT

Mitochondrial Dysfunction Is A Leading Hypothesis

Repeated findings point to inappropriate mitochondrial respiration across tissues as a common pattern.
This suggests a systemic metabolic impairment rather than a purely muscle-specific problem.

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Why can exercise cause post-exertional malaise (PEM) in complex chronic illnesses like ME/CFS and Long Covid, and how do we avoid the crashes?

If you experience a crash after a period of exertion, if traditional methods of ‘increasing fitness’ actually leave you with terrible side effects, this podcast is for you.

In this episode of Make Visible, physiotherapist and exercise scientist Todd Davenport joins Emily Kate Stephens to delve into the complex relationship between exercise, energy systems, and PEM in conditions like ME/CFS and Long Covid.

Davenport explains why traditional exercise approaches can actually be harmful for people with PEM, which he prefers to term post-exertional symptom exacerbation (PESE) or post-exertional neuroimmune exhaustion (PENE) to more accurately describe this hallmark symptom. He discusses how tools like the two-day cardiopulmonary exercise test (CPET) show impairments in oxygen use and energy production, and he talks us through how keeping the body below “ventilatory anaerobic threshold” using heart rate monitoring, pacing, and individualized activity management can slowly improve symptom burden and baseline – without triggering crashes.

This conversation challenges long-held assumptions about deconditioning and offers a nuanced, physiology-informed, individualized approach to care, that patients can manage themselves.

Topics include:

Why exercise can worsen symptoms in ME/CFS and Long Covid
What two-day CPET reveals about oxygen use and metabolism
Is it post-exertional malaise or deconditioning?
Using heart rate monitors for pacing
Differences between ME/CFS, Long Covid, and POTS

And Emily Kate is once again joined by Gez Medinger to break down the ideas presented by this week’s guest, relating it to their own experiences of living with energy limiting conditions.

Todd Davenport is Professor and Chair of the Doctor of Physical Therapy (DPT) Program at University of the Pacific. His clinical and academic interests as a physical therapist and exercise scientist revolve around complex chronic conditions (commonly preceded by an infection) such as ME / CFS (myalgic encephalomyelitis) chronic fatigue syndromes and Long Covid, working to understand the systems-level pathophysiology of post-exertional malaise /post-exertional neuroimmune exhaustion.

Explainers:

Anaerobic Ventilatory Threshold

CPET testing

Oxidative phosphorylation

Mitochondrial Impairment

Neuroimmune Exhaustion

You can find guidelines for pacing with a heart rate monitor to minimize PEM in ME/CFS and Long Covid here.