Long COVID is the presence of signs and symptoms that develop following a COVID-19 infection which continue for 12 weeks or more (and are not explained by an alternative diagnosis). This can affect both people who have been hospitalized or those who were not. These symptoms can come and go or fluctuate over time. Long COVID has been recognised as a separate entity (sometimes under different names) by the CDC, WHO and NICE. It’s difficult to know the true prevalence of Long COVID but some estimates put it at 3% to 12% of people who have had COVID-19 with some studies reporting numbers as high as 80% of infected people developing one or more long term symptoms.
A comprehensive review published in Nature looked at 15 studies. The most common long term symptoms reported were as follows:
Symptoms are reported to be worse in females under the age of 50 when compared to males. Females were five times more likely to report persistent symptoms especially fatigue, over five times more likely to report a new disability, and over six times more likely to have increased breathlessness.
Some signs of Long COVID have been reported by users of wearables. Heart rate variability (HRV) which is persistently lower than baseline, low “recovery” or “readiness” scores, increased respiratory rate and other markers have been reported after recovering from a COVID-19 infection.
The exact mechanism remains poorly understood and is likely different depending on the symptom. The virus can persist in the body for a prolonged period even if the acute illness has resolved which may be one cause of Long COVID symptoms. The immune response to the virus can sometimes be misdirected causing an autoimmune reaction where immune cells attack different organs such as the heart or lungs causing long term damage. Cognitive symptoms can be caused by increased inflammation in the brain observed during the acute infection which can leave behind long term damage. Muscle cells express the ACE-2 receptor which is used by the virus to attach to cells. Involvement of muscles in another proposed cause of long term fatigue.
Long COVID is a medical condition and should be managed by a healthcare professional.
In this article I focus on physiotherapy techniques that may help with some symptoms of Long COVID especially fatigue and breathlessness. Some people may benefit from exercise therapy for managing fatigue but it is important to note that the National Institute for Health and Care Excellence (NICE) has cautioned against using graded exercise therapy for all people without assessing the risk of harm. This is due to the risk of worsening symptoms induced by exercise that some people experience or post-exertional symptom exacerbation. Especially those with conditions such chronic fatigue syndrome. Other common and more serious symptoms can require more specialised medical attention.
Pacing one’s physical activity is a safe and effective way of managing fatigue and post-exertion malaise in most people. It should be guided by a physiotherapist or healthcare professional. Pacing refers to the strategy of exerting less activity than you have energy for. The idea is to avoid the crash when depleting your energy which can trigger post-exertional symptom exacerbation.
Activity levels then are increased very gradually in accordance to symptoms and tolerance. It is encouraged to increase levels by approximately 10% every few days. This can be in the form of strengthening exercises or the amount of walking one does. Another way to pace your activity is to monitor your heart rate and aim to not exceed 15 beats per minute above your average heart rate. You continue to gradually build up your activity until you reach your normal levels.
Breathing exercises can help lungs recover from the long lasting effects of a COVID-19 infection. They can also help with stress and anxiety which can arise from having lingering symptoms. Breathing exercises have been shown to improve the function of the diaphragm and increase lung capacity which is a marker of lung function.
A simple way to know if you are working too hard to breathe is to notice if you can hear your breathing. Normal breathing should be effortless and quiet. If you can hear your breathing you might be working too hard. Here are some examples of breathing exercises recommended by physiotherapists:
1. Sit upright on the edge of your bed or in a sturdy chair.
2. Reach your arms overhead and create a big stretching yawn.
3. Bring your arms down and finish by smiling for three seconds.
4. Repeat for one minute.
This exercise uses motion with deep breathing, to help build coordination and strength in the arms and shoulders. It also opens up the chest muscles to give the diaphragm space to expand.
1. Sit upright on the edge of your bed or in a sturdy chair.
2. Place your hands around the sides of your stomach.
3. With your lips closed, breathe in gently through your nose and feel your stomach rise/expand.
4. Once your lungs are full, keep your lips closed and exhale while humming, making the “hmmmmmm” sound. Notice how your hands lower back down.
5. Again, inhale through your nose, then exhale through your nose while humming.
6. Repeat for one minute.
Long COVID remains poorly understood and likely an under-managed condition that large numbers of people are suffering from in varying degrees. It is crucial to seek medical attention from a professional if you think you may be suffering from Long COVID symptoms.
https://www.nature.com/articles/s41598-021-95565-8
https://www.medrxiv.org/content/10.1101/2020.10.21.20216192v2
https://www.sciencedirect.com/science/article/pii/S0306987720314742
https://www.nature.com/articles/s41423-020-00550-2
