UTC   Um well absence of research isnt research evidence of absence Theres no severely affected patients in that lot and they were only exercised modestly with regard to their illness status the more sufferers push themselves the more aggravated symptoms and weakness should be The sort of people who apply for exercise testing are not likely to be already on the verge of a relapse or struggling to cope at work or even at home If some of them have practical help or accomodating family they would do worse in the same tests without it Gosh no mention of exertional insomnia even  Most of these studies arent looking into a variety of somatic symptoms or even pain only fatigue and functional strength though the latters good enough a demonstration of worsening after exercise for me At the end of the day its objective measures are most helpful  If good evidence is totally lacking you have to use next best evidence with caveats   You miss out a major notable source of good evidence in all the ME studies and synonymous diagnoses before c  or the s for instance papers by Acheson Gilliam Galpine Innes Compston Wallis et al  This is after all where exercise intolerance and severe multisystem symptoms were first described and recognised as a cardinal feature in nonremitting cases    There should also be some orthostasis studies Theres also Peckermans heart studies Les Simpsons trigger finger study the Da Costa study and so on Though they might not be focussing on symptoms the sort and extent of findings likely gives indirect suppport to the extend and breadth of symptoms      February