Medical Disclaimer: This article is intended for informational and educational purposes only. It does not take the place of medical advice or treatment from a licensed healthcare practitioner. Readers should consult their own doctor or a qualified healthcare practitioner for specific health concerns or questions.
Long COVID Physiotherapy; Expert guide to Recovery Management.
By Clarance Ezinwa PT
Introduction
Are you among the estimated 65 million people (approximately 17 million adults in the US) currently living with Long COVID?? Then this article is for you. Following the COVID-19 pandemic, health experts are facing a growing concern: Long COVID, which occurs weeks, months or years after an initial COVID infection, with varying degree of symptoms and severity.
Physical therapy has been identified as a crucial aspect of rehabilitation of patients with long COVID, as it can help improve symptoms and overall physical function. In this article, you’ll discover effective exercises, treatment plans and symptom relief techniques that would aid an easy transition from complications that arise from Long Covid to full health.
Let’s now define Long COVID and explain in detail how Physical Therapy can help relieve painful symptoms and assist in restoring function .
Definition Of Long COVID
COVID-19 is a viral disease caused by infection of SARS-COV-2. Long COVID is a complication that results during or after the initial infection. It is a patient-centered term coined by experts during COVID-19 pandemic to refer to people suffering from long term COVID symptoms. There is no universal definition of Long COVID right now, though several experts and authorities around the world have had significant strides in telling us what it is.
The WHO defines Long COVID as the continuation or development of new symptoms 3 months after the initial COVID infection, lasting more than 2 months with no other medical explanation.
Other researchers have defined Long COVID as a cluster of health related problems that appear or persist after an initial period of COVID-19 infection, persisting for weeks, months or years depending on various factors such as asthma.
Some people diagnosed with Long Covid may not be able to point out the time they were initially infected with COVID, some are able to, while some may have Long Covid as a result of reinfection with COVID virus multiple times.
Key Characteristics Of Long COVID
Definition | There is no universal definition as of now but health professionals believe Post COVID syndrome to be a group of deliberating illnesses that occur during or after an initial infection of COVID-19 virus. |
Duration | Could be weeks, months or years. In some cases, it could be lifelong. |
Associated Terminologies | It could be referred to as Long Haul COVID, Post-COVID syndrome, Post COVID-19 conditions, Post Acute COVID-19. |
Female gender, asthma, obesity, age. |
Understanding Long COVID: Symptoms and Effects on Physical and Mental Health.
To really understand Long COVID, let’s list out common symptoms and explain their effect on physical and mental health.
Symptoms Of Long COVID
According to CDC approximately 200+ Long COVID symptoms have been identified. These symptoms may last weeks, months, or sometimes a lifetime after an initial COVID -19 illness. They can emerge, persist, resolve and re-emerge over different lengths of time.
Long COVID symptoms could also be difficult to recognize or diagnose, require comprehensive care or result in disability.
The CDC explains that Post COVID symptoms often get worse after mental or physical effort, a process called post-exertional malaise. Commonly reported symptoms include:
fatigue,
memory problems,
shortness of breath,
sleep disorders.
additional symptoms includes:
headaches,
mental health issues,
initial loss of smell or taste,
muscle weakness,
fever,
cognitive dysfunction (brain fog)
Effect of Long COVID on physical and mental health.
The National Library of Medicine reports that
fatigue,
pain,
arthralgia, and
reduced physical capacity for activities of daily living were observed to be among the most common physical effects of Long COVID.
Many symptoms of Long COVID also border on the Mental terrain. In addition to symptoms highlighted in the previous section, mental struggles among patients include:
Anxiety
Depression or other mood changes
Concentration or memory problems
Sleep disturbances
Researchers at the Department of Psychiatry, University of California note that scientists have yet to definitively say why Mental symptoms present or persist, but have been able to make hypotheses as to why they think they occur. They think:
Post Covid syndrome is a debilitating multi system disorder; multiple pain and toxic signals overloading the neural pathways can leave a special effect on the brain.
Mental symptoms could also be as a result of long term breathing problems or fatigue with no end in sight.
Being hospitalized for a long time especially in the intensive care unit can give rise to post intensive care syndrome, critical illness myopathy, or critical illness polyneuropathy.
It’s important to make sure patients feel heard and taken care of, and proper education and expectations on disease progression are communicated to patients and caregivers.
Role Of Physiotherapy In Long COVID recovery
Physiotherapy is a vital component of the treatment strategy for people with long-term COVID. Physiotherapy plays a multifaceted role in addressing and alleviating symptoms, improving the overall well-being of affected patients. In addition to exercises, physiotherapists may use techniques such as manual therapy.
As each patient is specific due to their presentation of symptoms. Physiotherapist (among other health professionals) are tasked to create a concrete rehabilitation plans that border on;
Comorbidities (such as hypertension, obesity, CAD etc)
Direct lung trauma
Injuries to other organs and systems due to COVID 19.
Discharge plans
Estimated plans of discharge
Physiotherapy Assessment, Red Flags and Treatment of Common Symptoms
Before physical therapists are able to make a diagnosis and create a patient centered treatment plan for Long Covid, they have to run some assessments on the patient.
Physiotherapy Assessment for Long COVID Patients
Let's look into the comprehensive assessment plan physical therapists prepare to best assist Long COVID recovery.
History of Long COVID Patients.
Past medical history in relation to the initial COVI-19 infection is important even before scheduling an appointment with a physiotherapist. To create a good past medical history map, physios asks these questions:
Was the patient hospitalized due to COVID-19?
If not hospitalized, when did symptoms start?
When did symptoms last occur?(If unsure, when did the fever subside?)
If hospitalized: Discharge date? Admitted to the Intensive Care Unit (ICU)? Number of days in ICU?
Were diagnostic tests conducted to confirm COVID-19 negativity?
The goal of doing all of these is to also assess the patient's current viral load as it is the best evidence that would suggest the probability of reinfection.
Review of System
According to an article on Physiopedia, a review of the system is usually done to check potential effects Long COVID could cause across multiple systems.
Relevant Medical Investigations
The patient is then sent out for further investigations such as
Laboratory
Pulmonary Function tests
Radiograph results.
Objective Examinations.
Here the physiotherapist carries out evidence based tests to ascertain the levels of physical, mental and emotional dysfunction.
Vitals
The following vitals are taken to measure and track possible over exertion during or after treatments sessions. They include:
Blood pressure,
pulse pressure,
respiratory rate and
oxygen saturation.
Observation
Observational assessments begin as soon as the patient is in the line of sight of the physical therapist. Things Physical therapist look out for are:
Posture
Gait (use of assistive devices) and quality of gait
Unsteadiness (quick grasp of balance deficits)
Facial expressions of discomfort
Ease of changing positions
Ease of talking
Note any skin ulcers from positioning if patient had been hospitalized
Functional tests: 6 minutes walk test, time up and go test, 10 meter walk test are carried out to assess the patient level of functionality.
Other specific assessments across different systems are also carried out, these includes:
Neurological Assessment
Strength Testing
Movement Testing.
Potential red flags during Physiotherapy Assessment of Long COVID
While assessing patients with Long COVID, there are some red flags physiotherapists look out to avoid worsening Post COVID symptoms and maximize recovery. They Include:
Exertional Desaturation (low oxygen levels during exercise)
Cardiac Impairment (heart problems)
Post-Exertional Symptom Exacerbation (PESE), characterized by worsening symptoms after physical activity
Orthostatic Intolerance, marked by dizziness or lightheadedness when standing upright
Understanding Post-Exertional Symptom Exacerbation
Also called PESE. Symptoms can manifest immediately or 12-72 hours post-exercise, persisting for hours to weeks. Common symptoms include:
Fatigue
Pain
Dyspnea (shortness of breath)
Cognitive Impairment (brain fog)
Managing PESE and Orthostatic Intolerance
To mitigate PESE, individuals should:
Track symptom duration, intensity, and triggers
Employ energy conservation techniques to reduce flare-ups
Avoid increasing rehabilitation intensity without considering PESE
Physiotherapist must also address Orthostatic Intolerance symptoms, such as:
Dizziness
Breathlessness
Lightheadedness (presyncope)
Fainting (syncope).
Treatment for Common Symptoms of Long Covid; Physiotherapy Strategies
Physiotherapists suggest multiple forms of therapeutic exercises and modalities for patients according to their
1. clinical condition,
2. current physical fitness
3. exercise habits before COVID.
The most important concern is post-exertional exaggeration of symptoms(already explained above) . Patients are advised to be very cautious.
Different physiotherapy strategies used in managing Long COVID symptoms are:
Breathing exercises for respiratory issues in Long COVID
There are several types of breathing exercises that could help relieve respiratory distress caused by Long COVID, they are: Diaphragmatic breathing, pursed lip breathing, alternate lip breathing etc
Dr Peiting Lien of John Hopkins Medicine explained diaphragmatic breathing, (also called belly breathing) as beneficial in restoring diaphragm function and increasing lung capacity.
This exercise is broken down into phases. It’s important to not rush recovery, as it could be injurious to the body. It’s important to only progress to the next phase if you don’t feel too out of breath.
Phase One
Step 1: Comfortable Positioning
Lie on your back with your knees slightly bent, feet flat on the bed.
Step 2: Hand Placement
Place your hands gently on your stomach.
Step 3: Breathe Deeply
Close your mouth and place the tip of your tongue on the roof of your mouth.
Inhale slowly through your nose, filling your stomach with air (your hands should rise).
Exhale slowly through your nose, letting your hands fall.
Step 4: Repeat and Relax
Repeat this deep breathing cycle for 1 minute, focusing on relaxing your body.
Phase Two (Breathing on Your Stomach)
Step 1: Positioning
Lie on your stomach with your head resting on your hands, ensuring comfortable breathing.
Step 2: Breathing Technique
Close your mouth and place your tongue on the roof of your mouth.
Inhale slowly through your nose, filling your stomach with air.
Focus on your stomach pushing into the mattress as you breathe.
Exhale slowly through your nose.
Step 3: Repeat and Relax
Phase Three (Deep Breathing While Sitting)
Improve lung function and reduce stress with this seated deep breathing exercise, ideal for Long COVID recovery.
Step 1: Positioning
Sit upright on the edge of a bed or in a sturdy chair.
Step 2: Hand Placement
Place your hands around the sides of your stomach.
Step 3: Breathing Technique
Close your mouth and place your tongue on the roof of your mouth.
Inhale slowly through your nose, filling your stomach with air.
Try to spread your fingers apart with your breath.
Exhale slowly through your nose.
Step 4: Repeat and Relax
Phase Four (Deep Breathing While Standing)
Step 1: Positioning
Stand upright with feet shoulder-width apart.
Step 2: Hand Placement
Place your hands around the sides of your stomach.
Step 3: Breathing Technique
Close your mouth and place your tongue on the roof of your mouth.
Inhale slowly through your nose, filling your stomach with air.
Try to spread your fingers apart with your breath.
Exhale slowly through your nose.
Step 4: Repeat and Relax
Physiotherapy Strategies for Treatment of Chronic fatigue and Weakness in Long COVID
Chronic fatigue in Long COVID is a feeling of persistent tiredness or weakness that does not improve with rest. Despite the fact that fatigue is sometimes referred to as tiredness, fatigue is not the same as being tired or sleepy.
According to Long COVID Physio, fatigue experienced by people living with Long COVID can be experienced alongside post-exertion symptoms exacerbation. Exercise is not recommended as a rehabilitation intervention for people experiencing fatigue and post-exertional symptoms exacerbation.
Researchers at Sheffield Hallam University explains that rehabilitation of Fatigue in Long COVID involves paying attention to the three P’s which are prioritizing,pacing and planning.
Prioritizing
To beat fatigue, start by tracking which activities make you feel more or less tired. This will help you:
Prioritize your tasks and time.
Focus on energy-boosting activities.
Save energy for what matters most.
Pacing
Pacing yourself for energy management involves identifying essential activities, you can:
Prioritize tasks: focus on must-do's, delegate when possible, and adjust non-essential tasks.
Pace yourself: break tasks into smaller chunks, work at a slower pace, and take regular breaks.
Seek support: ask family, friends, or professionals for help when needed.
Ensure to
Stop and rest when feeling fatigued.
Adjust activities based on energy levels.
Prioritize self-care.
Planning
This involves putting the pieces together without creating a significant increase in fatigue symptoms.
A comprehensive guide to combat Chronic Fatigue is outlined in this book authored by researchers at sheffield Hallam University
Exercise Programs For Building Strength and Endurance in Long COVID recovery
Moderate intensity exercises have been proven to be beneficial in building strength and endurance in Long COVID patients. However, it’s important to start these exercises in phases, so as to warm up the body for further exertion.
Exercises such as: Deep breathing, Gentle walking, stretches, are really good gateway exercises for Long COVID patients.
Patients with respiratory symptoms and chronic fatigue should be closely monitored to prevent relapse of already resolving symptoms or post exertional malaise.
Moderate intensity exercises used in building strength and endurance includes:
Brisk walking
Resistance exercises like press ups and inclines
Aerobic exercises like dancing, supervised swimming, jogging for short distances.
These exercises have been proven to help patients with Long COVID feel stronger and combat frequent tiredness.
Physiotherapy Exercises for Improving Mobility in Long COVID
Physiotherapists use a range of manual therapies to improve joint mobility and limit pain. This include patella mobilizations and ankle pump exercises.
John Hopkins Medicine released a 14 page book to properly guide Long COVID patients on the pathway to restoring mobility. Check it out here for effective strategies
For further study, check out Dr Peiting Lien of John Hopkins Medical Network Youtube video on Improving Mobility in long COVID.
Flexibility and Stretching Exercises for Long COVID recovery.
Enhance Long COVID recovery with gentle stretching and flexibility exercises. Reduce stiffness, improve mobility, and boost overall well-being with these simple stretches:
Chin to Chest Stretch
1. Sit comfortably in a firm chair.
2. Slowly bend your head forward, chin toward chest.
3. Hold for 15 seconds.
4. Repeat 2-4 times.
Chin to Chest Diagonal Stretch
1. Gently turn your head to the side.
2. Tilt your head diagonally toward your chest.
3. Hold for 15 seconds.
4. For added stretch, use your hand to gently pull your head forward.
5. Repeat 2-4 times on each side.
Managing Anxiety and Depression in Long COVID
The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends an interdisciplinary treatment approach that may include physical medicine and rehabilitation, individual and group psychotherapy, and neurorehabilitation.
According to Yale Medicine, some pathways to introduce in Long COVID recovery as it relate to mental symptoms includes:
Cognitive Behavioral Therapy (CBT): Collaborate with a therapist in-person or online through telehealth services to reframe thought patterns and cope with emotional challenges.
Mind-Body Connections: Explore calming practices like meditation, yoga, or relaxation techniques to alleviate anxiety and promote serenity.
Holistic Healing Approaches:
Mindfulness exercises
Breathing techniques
Progressive muscle relaxation
Guided imagery
Reclaim Control:
Set realistic goals and priorities
Practice self-compassion and self-care
Connect with support groups and healthcare professionals
Drugs like Selective Serotonin Uptake Inhibitors can also be employed to balance changes in mood associated with Long COVID recovery.
Summary of key points
Long COVID is a cascade illness consisting of persistent symptoms 3+ months after initial COVID-19 infection
200+ symptoms have been identified, including fatigue, memory problems, shortness of breath, sleep disorders, and brain fog
Physiotherapy s a vital component of rehabilitation strategies aimed at Long COVID treatment
Physios helps address symptoms, improves physical function, and enhances well-being
Patient centered rehabilitation plans consider each Long COVID patient individually assessing their comorbidities, lung trauma, and other factors
Comprehensive assessment: medical history, review of systems, lab tests, and objective examinations
Treatment strategies: Breathing exercises, (diaphragmatic breathing), Exercise programs (moderate intensity), Manual therapies (joint mobilizations), Flexibility and stretching exercises, Management of chronic fatigue, anxiety, and depression
Recovery tips include prioritizing, pacing, and planning activities to manage fatigue; practicing self-compassion, self-care, and mindfulness
Connecting with support groups and healthcare professionals
Consider cognitive behavioral therapy (CBT) and mind-body approaches
Manage fatigue, anxiety, and depression is essential for recovery.
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