Over the last year and a half, we have all been affected by COVID-19 in some way. Those who have been infected and survive should return to a symptom-free, relatively normal life within a few weeks. In fact, over half of non hospitalized patients are symptom-free one month after they first experience symptoms (1). However, that is not the case for everyone infected with COVID-19. There is a subset of individuals who experience prolonged symptoms of COVID-19 for weeks, if not months, despite having survived the initial infection. These individuals have dubbed themselves COVID Long Haulers or those living with long COVID.
Who is a COVID Long Hauler?
Long COVID has been defined as a “multi-system disease with a complex array of respiratory, neurological, cardiovascular, gastrointestinal, musculoskeletal, rheumatological, dermatological and immunological symptoms ranging in severity, frequency and duration” lasting greater than 12 weeks (2) Only 10% of people who test positive for COVID-19 go on to experience prolonged symptoms (>12 weeks) (2), 20% of which are young adults without chronic health conditions (3).
Typical symptoms of long COVID may include shortness of breath, muscle aches, mental and physical fatigue, cognitive dysfunction, headaches, sleep disturbances, GI distress, anxiety, depression, and reactivation of fevers (2, 4, 5). Dealing with one if not multiple of these symptoms would be challenging, however, Long Hauler’s consistently report that they feel the greatest limitation with physical exertion resulting in difficulty or inability to perform activities of daily living, occupational tasks, and caring for themselves and family members.
The American Physical Therapy Association’s (APTA) vision is to “transform society by optimizing movement to improve the human experience”, which makes Physical Therapists instrumental in helping Long Hauler’s overcome their limitations and return to a fulfilling life. Due to the complexities of long COVID, physical therapists can facilitate referrals to other health care professionals including cardiology, pulmonology, physical medicine and rehab, and mental health professionals as necessary.
Pace, Plan, Prioritize
Returning to a fulfilling life means something different to everyone, and achieving this with long COVID requires a different approach for each individual. Some may require supervision and guidance from a health care professional. When it comes to increasing physical activity or exercise following a COVID-19 infection it is important to abide by the principles: pace, plan, prioritize (2) Due to the extensive physical and mental fatigue that can be experienced following a COVID-19 infection, and the fact that individuals can relapse when over-exerting themselves, a tactical and calculated plan for activity is required. Individuals should not try to be active or return to exercise at the same frequency, intensity or duration as prior to their infection (PACE). They should systematically think about how and when they are going to be active (PLAN). And, they should choose to do activities that are important to them (PRIORITIZE) so that they feel accomplished, are making progress with their goals, and prevent feelings of anxiety, depression, or helplessness.
A typical return to activity progression may look something like this:
However, COVID long haulers may require prolonged time in each stage. Gauging appropriate intensity, duration, and frequency of activity is a difficult thing to do, and often requires some trial and error. As a result, individuals may find that they need to regress a step while recovering. This is normal and should be taken as a learning experience to fine-tune activity intensity and duration. Tools like the BORG dyspnea scale and Rating of Perceived Exertion (RPE) can be used to assess how strenuous an activity is. A person recovering from long COVID should aim to keep their RPE < 6/10, and a BORG dyspnea scale in the 3-4/10 range.
Now that we know when it is safe to return to exercise after a COVID-19 infection, it is of the utmost importance to know when to stop exercising. It has been found in patients with a history of COVID-19 infection, that pushing yourself too much can result in excessive fatigue and relapse of symptoms. The following are red flag symptoms (meaning stop exercises immediately if you experience this) with exercise.
– Chest pain or heart palpitations
– Heart rate not proportional to exertion level or prolonged heart rate recovery
– Dizziness or lightheadedness
– Shortness of breath, difficulty catching breath, rapid breathing
– Excessive fatigue
– Swelling in the extremities
– Syncope (passing out)
– Tunnel vision or loss of vision
Long COVID is an unpredictable conglomerate of signs and symptoms that affect individuals in varying intensities and durations. It is important to increase one’s physical activity after appropriately recovering from a COVID-19 infection, but this can be challenging to do due to prolonged symptoms and fears. If you or someone you know is experiencing this, remember; pace, plan, and prioritize your activities, choose activities you like to do or that make you feel accomplished, keep in mind the red flags to exercise safely, and enlist the help of a physical therapist or other health care professionals to assist you in achieving your goals. This may be a long process and everyone will have a different experience, so persevere, stay positive and the results will come!
- Fernández-de-las-Peñas C, Palacios-Ceña D, Gómez-Mayordomo V, Cuadrado ML, Florencio LL. Defining post-COVID symptoms (Post-Acute COVID, Long COVID, Persistent Post-COVID): An Integrative Classification. Int. J. Environ. Res. Public Health. 2021; 18: 2621.
- Humphreys H, Kilby L, Kudiersky N, Copeland, R. Long COVID and the role of physical activity: a qualitative study. BMJ Open. 2021; 11.
- Vehar S, Boushra M, Ntiamoah P, Biehl M. Post-acute sequela of SARS-CoV-2 infection: caring for the ‘long-jaulers’. Cleveland Clinic Journal of Medicine. 2021; 88 (5): 267-272.
- Returning to sports or exercise after recovering from COVID-19. Cleveland Clinic. https://health.clevelandclinic.org/returning-to-sports-or-exercise-after-recovering-from-covid-19/amp/. February 15, 2021.
- Christian C, Stevens S, Davenport T. Rehabilitating COVID-19 “long haulers”: the ME/CFS connection. Medbridge. https://www.medbridgeeducation.com/blog/2020/08/rehabilitation-options-for-covid-19-long-haulers-the-me-cfs-connection/. August 4, 2020.
- Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiology. 2020; 5(10): 1085-1086.
- Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, Ohtake PJ. Home and community-based physical therapist management of adults with post-intensive care syndrome. PTJ. 2020; 100 (7): 1062-1073.
- Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S. PM&R and pulmonary rehabilitation for COVID-19. American Journal of Physical Medicine and Rehabilitation. 2020.
- Metzl JD, McElheny K, Robinson JN. Scott DA, Sutton KM, Toresdahl BG. Considerations for return to exercise following mild-to-moderate COVID-19 in the recreational athlete. HSSJ. 2020; 16: 102-107.