With ME/CFS, pacing comes first
NICE says activity "is never automatically increased", that people shouldn't "'push through' their symptoms", and that energy management "is not curative". Any Pilates has to fit inside your energy limits.
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Pilates guide
Pilates for chronic fatigue and ME/CFS: pacing first, post-exertional malaise, what NICE says, and gentle moves
With myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), Pilates has to fit inside pacing, not the other way round. The defining feature of ME/CFS is post-exertional malaise (PEM): a worsening of symptoms after even small physical, mental, emotional or social effort, often a day or two later. The National Institute for Health and Care Excellence (NICE) advises against general exercise programmes and graded exercise therapy, and says not to push through. No trial has tested Pilates in ME/CFS, and nothing on this page is a cure.
Many people searching for chronic fatigue are tired for other reasons, and for some of those, such as fatigue with multiple sclerosis (MS) or after cancer treatment, Pilates classes can help.
This guide explains how to tell the difference, what post-exertional malaise means for any Pilates, what the evidence shows, gentle lying and seated moves in tiny amounts, long COVID, and when to stop and get help. There's no class to follow here, for the reason NICE gives.
The short version
Post-exertional malaise changes everything
Symptoms "can typically worsen 12 to 48 hours after activity and last for days or even weeks". So judge any Pilates over the next 2 to 3 days, not straight afterwards.
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No general exercise programmes
NICE advises against exercise that isn't part of a programme overseen by an ME/CFS specialist team, and against graded exercise therapy. A Pilates class or online course is a general programme, so this page offers moves and tiny amounts, not a class.
No trial has tested Pilates in ME/CFS
The only report is about one person, published in 2026 in a journal that isn't indexed in PubMed. It can't guide anyone.
Gentle movement still matters
NICE asks for movement "carried out in small amounts and spread out throughout the day", and the NHS says there's no evidence that resting completely helps. A few slow Pilates-style moves, lying or seated, can do that job.
Tired for another reason? That's different
Tiredness has many causes, and a GP should look for them. With fatigue from MS, cancer treatment or fibromyalgia, Pilates classes are reasonable and have some evidence; with ME/CFS, those results can't be carried over.
ME/CFS, everyday tiredness and fatigue with other conditions
What ME/CFS is
NICE suspects ME/CFS when debilitating fatigue that gets worse with activity and isn't significantly relieved by rest, post-exertional malaise, unrefreshing sleep and problems with thinking and memory have lasted at least 6 weeks in an adult (4 weeks in a child), with activity well below what it was. There's no test, and the diagnosis is confirmed after 3 months. It ranges from mild to very severe.
Not deconditioning
NICE rejects programmes "based on deconditioning and exercise avoidance theories as perpetuating ME/CFS". The US Centers for Disease Control and Prevention (CDC) warns that "Standard exercise recommendations for healthy people can substantially harm patients with ME/CFS".
Dizziness on standing, and sensitivity to light and sound
NICE lists dizziness, palpitations and fainting on standing or sitting up, and sensitivity to "light, sound, touch, movement, temperature extremes and smells". Action for ME notes that for some people, "activities done in sitting unsupported or standing up can be particularly challenging".
Everyday tiredness has many causes
The NHS lists not enough sleep, stress and low mood, hormonal changes, illnesses and medicines, and conditions such as sleep apnoea, iron deficiency anaemia, diabetes and an overactive thyroid. ME/CFS is one cause among many, so see a GP if you don't know why you're tired.
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Fatigue with other conditions
Fatigue is common with MS, after cancer treatment and with fibromyalgia, where exercise is part of treatment. Our Pilates guides for multiple sclerosis, cancer and fibromyalgia cover those, with classes.
Pacing comes first
Energy management is the core approachStrong evidence
NICE calls energy management "a self-management strategy led by the person themselves" that "includes all types of activity (cognitive, physical, emotional and social)". Activity is kept steady, raised only after a stable spell, and lowered when symptoms are worse. NICE says it "is not curative", and that "there is currently no cure". The ME Association's and Action for ME's pacing guides go into detail.
No general exercise programmes, and no graded exerciseStrong evidence
"Do not advise people with ME/CFS to undertake exercise that is not part of a programme overseen by an ME/CFS specialist team, such as telling them to go to the gym or exercise more, because this may worsen their symptoms." NICE also rules out programmes with fixed step-by-step increases, "for example, graded exercise therapy", and the NHS says graded exercise therapy "is not recommended for people with ME/CFS".
Complete rest isn't the answer eitherStrong evidence
NICE asks for ways to keep up joint movement, flexibility, balance and muscle strength, "carried out in small amounts and spread out throughout the day", with rest periods in every plan. The NHS says there's no evidence that resting completely helps.
If you'd like a programmeStrong evidence
NICE says "it should be overseen by a physiotherapist in an ME/CFS specialist team". It starts by finding your baseline at a level that doesn't worsen your symptoms, then drops below it, and adjusts up or down within your energy limits. NICE allows this; it didn't ban all exercise.
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When you're improving
The ME Association's pacing booklet suggests gentle yoga as one option when you're improving, built up gradually: "A sudden return to any form of more vigorous physical activity is not recommended." It doesn't mention Pilates.
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Post-exertional malaise and Pilates
What post-exertional malaise isStrong evidence
NICE defines it as "The worsening of symptoms that can follow minimal cognitive, physical, emotional or social activity, or activity that could previously be tolerated." Symptoms typically worsen 12 to 48 hours later and can last days or weeks, sometimes leading to a relapse.
Feeling fine afterwards doesn't mean it was fineEmerging evidence
Because PEM is delayed, judge any session over the next 2 to 3 days. In 5 small studies of two-day exercise tests, people with ME/CFS did worse on the second day, while people without it did slightly better.
A class is more than the moves
Getting there, getting down to and up from the floor, following instructions, talking, light and music all use energy, and the classical order strings 20 to 30 moves together without rest (our reading, from the symptoms NICE lists).
Source 1
Check for PEM
Our ME/CFS exercise guide has a 5-question check for post-exertional malaise, from a validated questionnaire.
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What the evidence says
There is no Pilates evidence in ME/CFS at all. The rest of the exercise evidence is disputed, and mostly comes from trials that didn't require post-exertional malaise.
No Pilates trial in ME/CFSStrong evidence
Our searches of PubMed, Europe PMC and ClinicalTrials.gov (October 2026) found no Pilates trial in ME/CFS or post-viral fatigue, and none registered. The only report is a retrospective case of one woman with ME/CFS and other conditions, in a journal not indexed in PubMed, by authors mostly from one Pilates studio, with no dose and other treatments at the same time. It isn't evidence of benefit.
The closest tested method: lying isometric yogaEmerging evidence
In a 2025 Japanese trial, 48 adults whose ME/CFS hadn't improved with usual care added about 12 weeks of lying isometric yoga: five poses "performed very slowly while breathing" at 30% to 50% of their strength, in one-to-one sessions about every 4 weeks with home practice. Daily functioning and fatigue improved more than with usual care alone. It was small, unblinded, from one research group, and left out the most severely affected. Pilates moves done the same way are untested.
Physiotherapy effects fade when PEM is requiredEmerging evidence
A 2021 review of 18 trials found that effects "seemed to disappear with more narrow case definitions, increasing objectivity of the outcome measures and longer follow-up".
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Exercise reviews in ME/CFS: disputedMixed evidence
A Cochrane review of 8 trials found exercise probably reduces fatigue at the end of treatment, but all its trials used criteria that don't require PEM, harms are very uncertain, and a pilot to update it was discontinued. Newer reviews found some reduction in fatigue, mostly at low certainty, with no Pilates trial among them. NICE weighed this evidence and still advises against graded exercise; this page follows NICE.
Pilates for fatigue in other conditionsMixed evidence
In a 2026 analysis of 205 trials in cancer-related fatigue, Pilates reduced fatigue about as much as cycling or qigong. In MS, across 22 trials, only Pilates delivered with remote sessions (telerehabilitation) significantly reduced fatigue, and no comparison reached high certainty. A 2026 review of Pilates across chronic conditions reports its fatigue result inconsistently in its summary, and we couldn't read the full text, so we don't rely on it.
Why those results don't carry overStrong evidence
None of those conditions has post-exertional malaise as a defining feature, and NICE rules out programmes developed for healthy people or for other illnesses.
What the Pilates principles can offer, and what to drop
Keep
Slow breathing, control, small ranges, and rest between moves: Pilates' own principles suit very short, very gentle movement (our reading).
Drop
The classical mat order, the hundred, roll-ups, teasers, planks, the standing series, flowing sequences, quick changes between the floor and standing, and long classes. They were built for fit, healthy bodies, and a full class is the kind of generalised programme NICE advises against.
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Rest and breathing, lying down
Slow breathing: a few minutes to start a rest, with no holds (our ME/CFS guide's editorial starting point); NICE says relaxation at the start of each rest period could be helpful. Lateral breathing: 3 to 5 easy breaths, optional (our editorial starting point; stop if you feel light-headed). Corpse pose as part of a planned rest. The move pages' own doses are for people without ME/CFS.
Gentle movement, lying down
Only on a stable day and within your energy limit: 3 to 5 slow ankle circles each way, heel slides, shoulder circles and knee folds, choosing 2 or 3 of them, stopping well before you feel tired, spread through the day (our ME/CFS guide's editorial starting point).
Seated, for dizzy days
For days when standing makes you dizzy: 30 seconds of seated marching, or 3 to 5 rotations each side (our ME/CFS guide's editorial starting point); breath reach: 3 breaths, arms only as high as is comfortable (our editorial starting point).
When you're stable, with your ME/CFS physiotherapist
Only as part of a plan agreed with your ME/CFS team: 3 to 5 small, slow bridges (close to the isometric yoga trials' slow, small hip lift) and 3 to 5 sit-to-stands if standing is comfortable (our ME/CFS guide's editorial starting point), judged by how you feel over the next 2 to 3 days.
What to leave out
Classes, videos and programmes for healthy people
Including reformer classes and online Pilates courses: NICE says not to offer "generalised physical activity or exercise programmes" for ME/CFS.
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Fixed step-by-step increases
Add-a-minute-a-day plans and 30-day challenges, including ours, work the way graded exercise therapy does, which NICE advises against.
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Quick changes between the floor and standing
If you get dizzy on standing, stay lying or seated, and change position slowly (our suggestion).
Hot Pilates
NICE lists sensitivity to temperature extremes among ME/CFS symptoms, and no study has tested hot classes in ME/CFS. We'd avoid them.
Forced or fast breathing
Keep the Pilates breath slow and easy, and go back to normal breathing if it feels like an effort (our suggestion).
Why there's no class here
NICE advises against general exercise programmes
NICE says not to offer people with ME/CFS "generalised physical activity or exercise programmes", including programmes developed for healthy people or for people with other illnesses. A follow-along Pilates class on a website would be exactly that, so we don't offer one. Start with pacing instead, and if you'd like a physical activity programme, ask for one from a physiotherapist in an ME/CFS specialist team.
Routines that may fit, with conditions
The slow breathing in our breathing exercises to relax routine, at the start of a rest (leave out the holds). Our long COVID gentle routine only if you have long COVID without post-exertional symptoms, or your long COVID team agrees (our suggestion).
Fatigue from another condition
If your tiredness comes with MS, cancer treatment or fibromyalgia, our Pilates classes for those conditions are for you. They are for tiredness from that condition, not for ME/CFS.
Long COVID
Check for post-exertional symptoms firstStrong evidence
World Physiotherapy says "Graded exercise therapy or fixed activity prescription should not be used" with post-exertional symptoms, and that with them, "'Stop. Rest. Pace', activity management or pacing, and heart rate monitoring may be effective". In 213 people with long COVID, 58.7% met the thresholds for post-exertional malaise.
Pilates trials in long COVID didn't check for PEMEmerging evidence
In 49 adults, 12 weeks of face-to-face mat Pilates reduced fatigue, but the online version didn't; in 59 people, 8 weeks of Pilates improved walking distance, sleep and fatigue against no exercise. Neither screened for post-exertional malaise. A 2023 review urged more research before exercise therapies such as Pilates are widely used in long COVID.
So
Pilates for long COVID is reasonable only without post-exertional symptoms, or with your long COVID team's agreement. Our long COVID exercise guide explains the check.
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Severe ME/CFS and dizziness
Severe or very severe ME/CFS
Movement and positioning should be guided by your ME/CFS team. Family members or carers can help with moving in bed and changing position, as NICE describes.
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Dizzy when you stand up
Dizziness on standing is common with ME/CFS and can be postural tachycardia syndrome (PoTS). Keep moves lying or seated, change position slowly, and see your GP. Our Pilates for POTS guide has more.
Lie down and raise your legs until you feel better. If you can't lie down, sit, if possible with your head lowered between your knees, and drink some water.
Warning signs: when to stop and get help
These are the warning signs from our ME/CFS exercise guide and yoga for chronic fatigue guide, word for word. This is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999
Call 999 if you or someone else has any of these, and don't drive yourself to A&E:
- Sudden chest pain that doesn't go away, or that spreads to the arms, neck, jaw, stomach or back.
- Fainting while exercising or while lying down, or not waking up within 1 minute.
- Palpitations that don't go away, or that come with chest pain, shortness of breath or fainting.
See your GP or ME/CFS team
- New symptoms or a change in your symptoms: NICE says not to assume they're caused by ME/CFS.
- A flare-up or relapse you can't manage with your plan.
- You think you might have ME/CFS: there's no test, and other conditions need ruling out.
- You get dizzy, have palpitations or feel faint when you stand up.
- Before starting any exercise programme.
Tiredness you can't explain
You've been feeling tired for a few weeks and you're not sure why, your tiredness affects your daily life, you have other symptoms such as weight loss or mood changes, or you've been told you make gasping, snorting or choking noises when you're asleep.
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Stop, rest, pace
If your symptoms get worse during an activity or over the next 2 to 3 days, drop back and rest, and don't return to your usual level until the flare-up has settled.
If you spend most of your time in bed
Ask your team about protecting your skin, joints and circulation. Throbbing pain and swelling in one leg needs an urgent GP appointment or NHS 111, and if it comes with breathlessness or chest pain, call 999: it can be a blood clot.
If you're struggling with your mental health
If you don't feel you can keep yourself or someone else safe, call 999 or go to A&E. For urgent help, call NHS 111 and select the mental health option, or call Samaritans free on 116 123. In the US, call or text 988.
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Myths
"Push through fatigue to recover from ME/CFS"Strong evidence
NICE says people shouldn't "'push through' their symptoms", and that activity "is never automatically increased".
Source 1
"Pilates can cure chronic fatigue syndrome"Strong evidence
NICE says "there is currently no cure" and not to offer exercise as a cure, and there's no Pilates trial in ME/CFS.
"Any gentle Pilates class is safe with ME/CFS"Strong evidence
NICE advises against generalised exercise programmes, and a class adds travel, talking, light and noise to the moves.
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"Rest all day and do nothing"Strong evidence
The NHS says there's no evidence that resting completely helps, and NICE asks for small amounts of movement through the day.
"Pilates helps fatigue in MS and cancer, so it'll help ME/CFS"Strong evidence
Those conditions don't have post-exertional malaise as a defining feature, and NICE rules out programmes designed for other illnesses.
"NICE banned all exercise"Strong evidence
NICE allows a personalised programme for people who want one, overseen by an ME/CFS physiotherapist, and asks for gentle movement for everyone.
Source 1
"Pilates fixes adrenal fatigue"
Adrenal fatigue isn't a recognised medical condition; our yoga for chronic fatigue guide covers the review behind that. Tiredness that lasts needs a GP, who can look for the real cause.
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Read next
- Exercise and ME/CFS
- Yoga for chronic fatigue and ME/CFS
- Exercise for long COVID
- Yoga for long COVID
- Pilates for POTS
- Exercise for PoTS
- Pilates for fibromyalgia
- Pilates for multiple sclerosis
- Pilates during and after cancer
- Pilates for chronic pain
- Exercise for fibromyalgia
- Breathing exercises to relax
- The Pilates guide
Questions people ask
Is Pilates good for chronic fatigue syndrome (ME/CFS)?
It hasn't been tested: there's no Pilates trial in ME/CFS. NICE advises against general exercise programmes and graded exercise, so a Pilates class isn't a treatment. A few very gentle Pilates-style moves, lying or seated, can be part of keeping your body moving within your energy limits.
Can Pilates make ME/CFS worse?
Yes, if it's more than you can manage. Post-exertional malaise can follow even small physical, mental, emotional or social effort, typically 12 to 48 hours later. Judge any session over the next 2 to 3 days, and drop back if your symptoms get worse.
What does NICE say about exercise for ME/CFS?
Don't take up exercise unless it's part of a programme overseen by an ME/CFS specialist team, and don't use programmes with fixed step-by-step increases such as graded exercise therapy. If you'd like a programme, it should start below your baseline, with a physiotherapist in an ME/CFS team. Energy management (pacing) comes first.
Is Pilates the same as graded exercise therapy?
No, but a Pilates course with fixed increases (more reps or longer classes each week, whatever your symptoms) works the same way, and NICE advises against that. With ME/CFS, any Pilates should go up only after a stable spell, in small steps, and come down when symptoms worsen.
Which Pilates moves are safest with ME/CFS?
Slow, small moves lying down or seated, such as ankle circles, heel slides, knee folds and shoulder circles, 3 to 5 at a time and spread through the day, on a stable day (our ME/CFS guide's starting point). Leave out the hundred, roll-ups, planks, standing work and anything that leaves you breathless.
Can I go to a Pilates class with chronic fatigue?
With ME/CFS, a class is a lot more than the exercise: the journey, the conversation, the light and the noise all use energy, and NICE advises against generalised programmes. If you're stable and want to try something, a few minutes at home, lying or seated, agreed with your ME/CFS team, is a safer start.
Is reformer Pilates OK with ME/CFS?
It hasn't been studied. Reformer classes are usually full-length general classes, which NICE advises against for ME/CFS. If your ME/CFS physiotherapist builds a programme with you, they may use equipment; that's different from joining a class.
Is it normal to feel tired after Pilates?
Feeling pleasantly tired after a new class, or having sore muscles for a day or two, is normal. A worsening of your usual symptoms, often delayed, out of proportion to what you did and slow to recover from, is different: that can be post-exertional malaise. Our ME/CFS exercise guide has a 5-question check.
Does Pilates help fatigue from other conditions?
In some. In a large analysis of cancer-related fatigue, Pilates eased fatigue about as much as other exercise, and our Pilates for MS guide covers fatigue with MS. None of this applies to ME/CFS, where post-exertional malaise changes the picture.
Can Pilates help long COVID fatigue?
Two small trials reported less fatigue, but neither checked for post-exertional malaise. Many people with long COVID have it, and World Physiotherapy says graded exercise or fixed activity plans shouldn't be used then. Check for it first, as our long COVID guide explains.
I get dizzy when I stand up. Can I still do Pilates?
Dizziness on standing is common with ME/CFS and can be PoTS. Do moves lying or seated, change position slowly, and see your GP. Our Pilates for POTS guide has more.
How do I know if it's ME/CFS or just tiredness?
ME/CFS means fatigue that isn't relieved by rest, post-exertional malaise, unrefreshing sleep and problems with thinking and memory, lasting at least 6 weeks, with a big drop in what you can do. Many other things cause tiredness, so if you've been tired for weeks without knowing why, see a GP.
Sources
- NICE NG206 · Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (2021)
- NHS · ME/CFS: treatment
- PubMed, Europe PMC and ClinicalTrials.gov · Our searches for Pilates trials in ME/CFS, chronic fatigue syndrome, post-viral fatigue and long COVID (October 2026)
- De La Fuente-Reynoso 2026 · Clinical Pilates in one woman with ME/CFS (retrospective case report, WebLog J Phys Ther Rehabil; not indexed in PubMed; read in full)
- NHS · Tiredness and fatigue (past its review date: reviewed June 2023, review due June 2026)
- Xie 2026 · Exercise and mind-body treatments for cancer-related fatigue: 205 trials (network meta-analysis, Complement Ther Med)
- NHS · ME/CFS: diagnosis
- CDC 2024 · ME/CFS: strategies to prevent worsening of symptoms (US Centers for Disease Control and Prevention)
- Action for ME 2025 · What is pacing? (leaflet)
- Shepherd 2023 · Pacing: activity and energy management for people with ME/CFS and long COVID (ME Association booklet)
- Action for ME · Pacing and energy management
- NHS · ME/CFS: symptoms
- Lim 2020 · Two-day exercise tests in ME/CFS: 5 studies (meta-analysis, J Clin Med; read in full)
- Cotler 2018 · A brief questionnaire to assess post-exertional malaise (validation study, Diagnostics; read in full)
- Oka 2025 · Lying-down isometric yoga in 48 adults with ME/CFS (RCT, BioPsychoSocial Med; read in full)
- Oka 2017 · A lying-down isometric yoga programme in 12 people with severe ME/CFS (pilot study, BioPsychoSocial Med; read in full)
- Oka 2014 · Seated isometric yoga in 30 people with chronic fatigue syndrome (RCT, BioPsychoSocial Med; read in full)
- Wormgoor 2021 · Physiotherapy in ME/CFS when post-exertional malaise is required for diagnosis: 18 trials (systematic review, J Transl Med)
- Larun 2019 · Exercise therapy for chronic fatigue syndrome: 8 trials (Cochrane review, amended, with the 2024 editorial note)
- Liao 2025 · Exercise therapies for chronic fatigue syndrome: 20 trials (network meta-analysis, iScience; read in full)
- Zhao 2026 · Exercise for ME/CFS: 17 trials (systematic review and meta-analysis, J Psychosom Res)
- Nabil 2026 · Pilates in multiple sclerosis: 22 trials (network meta-analysis, BMC Sports Sci Med Rehabil; read in full)
- Abonie 2026 · Pilates for fatigue in chronic conditions: 18 trials (systematic review and meta-analysis, Disabil Rehabil)
- World Physiotherapy 2021 · Safe rehabilitation approaches for people living with long COVID: physical activity and exercise (briefing paper 9)
- World Physiotherapy 2021 · Fatigue and post-exertional symptom exacerbation (information sheet)
- Twomey 2022 · Chronic fatigue and post-exertional malaise in 213 people with long COVID (cohort study, Phys Ther)
- Cunha 2024 · Online and face-to-face mat Pilates in 49 adults with long COVID (RCT, Int J Environ Res Public Health; read in full)
- Jorge 2025 · Eight weeks of Pilates in 59 people with post-COVID-19 syndrome (RCT, J Bodyw Mov Ther)
- Chandan 2023 · Non-drug treatments for post-viral syndromes, including long COVID (systematic review, Int J Environ Res Public Health; read in full)
- NHS · Postural tachycardia syndrome (PoTS)
- NHS · Chest pain (past its review date: reviewed August 2023, review due August 2026)
- NHS · Fainting
- NHS · Heart palpitations
- NHS · Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS)
- NHS · DVT (deep vein thrombosis)
- NHS · Where to get urgent help for mental health (past its review date: reviewed April 2023, review due April 2026)
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.