Long COVID

A significant proportion of people with long COVID experience post-exertional symptom exacerbation: symptoms worsen substantially in the hours or days after activity that felt manageable at the time. In this group, fixed, quota-based graded exercise programmes can cause harm, and professional guidance advises against them 2.

So the first task is not to build fitness. It is to establish what level of activity can be sustained without triggering a crash, and to hold below it. Progression comes later, slowly, and only if it is tolerated.

Before any activity programme we screen for post-exertional symptom exacerbation, for orthostatic intolerance, and for cardiac and respiratory complications that need medical rather than rehabilitative management.

This screening determines the entire approach. Someone with breathlessness from deconditioning and someone with post-exertional exacerbation need almost opposite programmes, and they present similarly.

Breathing pattern disorders, treated with breathing retraining, although the evidence is limited: in a small randomised trial in young people with long COVID, a programme combining it with psychological support did no better than standard care 7. Orthostatic intolerance, managed with position-based conditioning and practical strategies. Deconditioning, where it is genuinely the problem. Cognitive difficulty. Fatigue, through pacing and activity management rather than through exercise progression.

Where there is no post-exertional exacerbation, conditioning proceeds as it would in any deconditioned patient — carefully monitored, but progressive.

Long COVID rehabilitation is a developing field and the evidence base is still thin in places. We will tell you where a recommendation rests on good evidence, where it rests on clinical reasoning, and where it is uncertain.

We do not offer protocols that promise resolution, because none has been shown to deliver it. What can be offered is careful management that avoids making things worse and supports gradual improvement where it is possible.

Where symptoms worsen substantially in the hours or days after activity, standard graded exercise can cause harm 2. Pacing has to come first and progression only follows once that pattern has settled.

This is screened for at assessment rather than assumed absent, because applying a conventional exercise programme to someone with this pattern is the commonest way these patients are made worse.

In trials, rehabilitation has helped. A 2023 meta-analysis of 14 randomised trials found moderate-certainty improvements in walking capacity and quality of life, although adverse events were reported too poorly to judge safety 3. In a UK trial of 585 adults who had been in hospital with COVID-19, an eight-week online programme of supervised exercise and psychological support modestly improved quality of life 4.

Rehabilitation studies have often not reported how many participants had post-exertional symptom exacerbation 5. It affects about a quarter of people with long COVID in community studies, and more than half in another analysis 56. For people who have it, professional guidance advises pacing and symptom-led activity rather than fixed graded exercise 2.