Rehabilitation guide
For people who have fatigue, breathlessness and difficulty thinking for months after COVID-19, movement can be an important part of recovery; but at the wrong dose it can make symptoms flare. This guide explains what long COVID is, what to look out for before you start exercising, how to pace your energy and gentle movements you can do at home.
According to the World Health Organization's definition, long COVID (post COVID-19 condition) consists of symptoms that usually appear 3 months after the start of the infection, last at least 2 months and cannot be explained by another illness. Symptoms may be new or may have continued since the illness; ups and downs and relapses are common. The UK guideline (NICE) calls symptoms lasting 4–12 weeks “ongoing symptomatic COVID-19” and those lasting more than 12 weeks “post-COVID-19 syndrome”.
The most common symptoms are fatigue, breathlessness and difficulty with attention and memory; these can markedly affect daily life.
The World Health Organization and World Physiotherapy recommend that the following are assessed before you start exercising:
For people with post-exertional symptom exacerbation, the World Health Organization recommends education in energy conservation and pacing, rather than pushing exercise. For fatigue, it recommends a cautious return to exercise adjusted to symptoms, together with pacing.
World Physiotherapy recommends that graded exercise programmes, which increase time or load at set intervals regardless of symptoms, are not used in long COVID, and that activity is adjusted each day according to symptoms.
In a randomised trial in Scotland with 233 people whose symptoms had lasted at least 4 weeks, personalised resistance exercises done at home every day for 3 months (lying down for those confined to bed, otherwise sitting or standing; arm exercises first, leg exercises from the third week) increased the distance on a walking test by an average of 36.5 metres compared with usual care. Grip strength, quality of life, and anxiety and depression symptoms also improved; fatigue and breathlessness measures did not differ.
In the REGAIN study of 585 people who had been in hospital with COVID-19 and had had problems for more than 3 months, an 8-week online, supervised group exercise and psychological support programme improved quality of life over a year; at 3 months 17% rated their health as “much better”, compared with 8%, and there was no sign that the programme caused harm. How far these results apply to people who were not in hospital and who have marked post-exertional flares is not known.
Exercises at home
The first three movements help manage breathlessness; the last three help you slowly regain strength and stamina. Do the last three only if you do not have post-exertional symptom exacerbation or your healthcare team has agreed. Adjust the dose to your symptoms each day: if your symptoms rise the next day, do less next time.
Sit comfortably, relax your shoulders and put one hand on your belly. Breathe in slowly through your nose and feel your belly rise, then breathe out slowly through your mouth. Do not force your breath.
A few minutes, several times a dayBreathe in through your nose, then purse your lips as if to whistle and breathe out slowly, taking about twice as long as you did to breathe in. You can use it when breathless or climbing stairs.
When you feel breathlessWhen you are short of breath, sit and lean forward, resting your elbows on your knees or a table. Relax your shoulders and breathe slowly in and out; carry on once your breathing settles.
When neededStand up from a sturdy chair and sit down with control. Do this only if you do not get a marked worsening after exercise; adjust the number to that day's energy.
Few enough that you do not feel worse the next day; for example, start with 5 repetitionsPlace your hands on a wall at chest height, bend your elbows to bring your chest towards the wall and push back. You can also start with arm exercises sitting or lying down.
According to your symptoms; start with a few repetitionsTake short walks around the house or nearby. If your symptoms do not get worse the next day, increase the time very slightly; on bad days, do less.
Short bouts adjusted to your symptomsTo relax, see the physiological sigh; to track your symptoms, see the pain diary.
In some people, yes. In some people with long COVID, symptoms worsen markedly after physical, mental or social effort, often 12 hours or more later; this is called post-exertional symptom exacerbation. World Physiotherapy recommends asking about it before recommending exercise. If you have it, pacing your energy should come before pushing exercise.
It means planning your activities to stay within a limit that does not trigger your symptoms. It is not avoiding activity; it is making progress without overdoing it on good days, with rest breaks built into the day. When your symptoms start to rise, stop, rest and rearrange your plan. A diary or an app can help you recognise your limit.
It is not recommended for people with post-exertional symptom exacerbation. World Physiotherapy recommends that programmes increasing time or load at set intervals regardless of symptoms are not used in long COVID, and that activity continuously adjusted to symptoms is preferred.
The World Health Organization strongly recommends that oxygen falling with effort and heart problems are investigated and treated before an exercise programme is started. Dizziness, palpitations or feeling faint on standing should also be assessed; in that case you may need to start with exercises done lying down or sitting.
In some groups, yes. In a study of 233 people in Scotland, personalised resistance exercises done every day for 3 months increased walking distance by an average of 36.5 metres compared with usual care and improved grip strength, quality of life, and anxiety and depression symptoms; however, fatigue measures did not differ. In another study of 585 people who had been in hospital with COVID, 8 weeks of online group exercise and psychological support improved quality of life over a year.
It varies a great deal from person to person. According to estimates reported by the World Health Organization, about 3.7% of those infected up to the end of 2021 developed long COVID, and 15% of them still had symptoms 12 months later. Most people improve over time; ups and downs in symptoms are common.
For people who were in intensive care, see the recovery after intensive care guide; for breathlessness, see the pulmonary rehabilitation guide.
In situations marked “emergency”, call 112:
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