Introduction

The longer-term impacts of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or more commonly referred to as COVID-19 infection have been described in the literature using varying terms, including “Long COVID”, “Long COVID-19”, “long-haul COVID”, “Post-Acute COVID-19″, “Post-COVID Conditions” and “Post-Acute Sequalae of SARS-CoV-2 infection (PASC)”^[1][2]. The term Long COVID was first coined as a hashtag by a patient in Italy early in the pandemic^[3] and is now widely recognised in the media, by patients, and in scientific literature^[4].

In an Australian context, the Parliamentary enquiry into Long COVID (2023) recommended that at this time the World Health Organization’s (WHO) definition of Long COVID be used clinically^[5].

For more information regarding the various definitions existing internationally please visit Chapter 1. What is Long COVID?

As the evidence continues to emerge regarding Long COVID, our understanding of the condition and the impact it has on patients affected by it continues to grow^[6][7]. With more than 760 million people having been diagnosed with COVID-19 worldwide since the beginning of the pandemic^[8], it stands to reason that we will continue to see an increasing number of people presenting to physiotherapy with symptoms and impairments that may be attributable to Long COVID either as a primary problem or a concurrent associated problem. As physiotherapists, regardless of our area of practice, it is vital we have an understanding of and awareness of Long COVID. This should include how to assess for, treat and manage the presenting impairments and/or limitations on activity participation of people experiencing Long COVID.

Whilst evidence continues to develop regarding the likely duration of the ongoing effects of an acute COVID-19 infection^[9][10][11], anecdotal and newer evidence suggests that some patients with impairments attributable to Long COVID improve over time^[12][13]. The specific timeline for recovery and symptoms experienced is however unique to each individual^[14].

The learning objectives included in this chapter were drawn from the results of a national Australian survey of 104 physiotherapists and physiotherapy students. A Pat Cosh Trust grant (administered by the Australian Physiotherapy Association) has enabled the development of this interactive chapter to support the optimal management of patients presenting with impairments who are recovering after COVID-19 infection: click here for more information about the development of the chapter. The content of the chapter has been drawn from international and national guidelines and peer-reviewed journal publications.

This chapter will cover the following topics:

The content has been peer-reviewed and will be updated periodically as new evidence related to the physiotherapy management of Long COVID emerges.

Impairments that may benefit from physiotherapy management

Long COVID is frequently described in the literature as being “multi-dimensional, episodic and unpredictable”^[15]. Presenting symptoms can vary widely from patient to patient^[16][17]. Patients can present with overlapping or clustered symptoms, which may change or fluctuate over time^[18].  Physiotherapists assist patients to improve their quality of life^[19] and it has been well documented that the symptoms of Long COVID can have a significant detrimental impact on health and wellbeing^[20]. As a result of the wide range of symptoms that may be present, patients with Long COVID may experience varying degrees of impairment that can impact physical, cognitive, mental and emotional health, all of which may impact on their activities of daily living and participation in education and exercise^[21].

There is no one test to diagnose Long COVID, rather it is considered a diagnosis of exclusion^[22]. It is also important to consider that presenting symptoms may be due to other factors such as underlying or pre-existing health conditions, complications from acute COVID-19 infection (such as DVT or PE), physical deconditioning that may have occurred after a long or complicated acute illness (such as post-intensive care syndrome), or even re-infection of COVID-19^[23][24]. As primary contact practitioners, physiotherapists should liaise with other members of the multidisciplinary team to further assist with refining medical diagnosis and differential diagnosis. Care should be adjusted as the team develops a greater understanding of the patient’s presenting clinical signs and symptoms and their response to therapy deepens.

Also, health professionals who possess an understanding of the common presenting symptoms may assist patients with Long COVID to allay any associated fear or frustration that they may experience when interacting with the health system^[25][26]. The fears or frustrations that may be expressed by patients with Long COVID include but are not limited to^[27]:

• Feeling let down or abandoned by healthcare services
  
• Feeling forgotten
  
• Not feeling listened to
  
• Feeling like symptoms are not believed or dismissed
  
• Frustration related to symptoms being attributed to other issues such as anxiety

“It has been an awful time and it made it worse when I felt that I wasn’t being believed about the symptoms. They put it down to anxiety disorder.”
(Male, Age unknown)^[28]
These fears and frustrations may be reinforced by health professionals, family, friends and employers. Taking time to listen and validate a patient’s experience is an important part of the overall management of patients with Long COVID^[29][30].

Common symptoms

Symptoms of Long COVID can affect all body systems. SARS-CoV-2 enters the body via the angiotensin-converting enzyme 2 (ACE-2) receptor^[31]. These receptors are located on cells throughout the body, giving the virus the capacity to infect and damage cells within multiple organs, which is reflected in the large variety and differing of symptoms that people with Long COVID may experience^[32][33].

For further information related more broadly to Long COVID and the symptoms, please visit Chapter 1. What is Long COVID?

Common symptoms of Long COVID^[34][35] that people presenting to physiotherapy may report include, but are not limited to:

A systematic review of studies including over 47,000 patients has identified the three most common symptoms experienced by people with Long COVID as being fatigue, cognitive and concentration impairment and shortness of breath^{[36][37][38][39]}.

Further to this, a 2022 meta-analysis^[40] including over 1.2 million patients from 22 countries reported on the prevalence of three common Long COVID symptom clusters with these being respiratory symptoms (described as ongoing respiratory problems), fatigue symptoms (described as persistent fatigue with bodily pain or mood swings) and cognitive symptoms (and related cognitive problems).

Episodic nature of Long COVID

Symptoms not only vary, but may also fluctuate and people with Long COVID can experience ‘false recovery’^[42]. The uncertainty and unpredictability of the future for patients with Long COVID can be a significant source of distress and may manifest in newly diagnosed or exacerbation of pre-existing psychological problems, particularly anxiety^[43].

Referrals to other health professionals

Due to the wide variety of possible symptoms and impairments, multiple health professionals or teams may be required to assist in the ongoing management of patients experiencing Long COVID, particularly when symptoms are not related to respiratory or physical function^[44]. Best practice management for patients with Long COVID would involve a multidisciplinary team either in a community setting or through Long COVID clinics^[45].

Long COVID Multidisciplinary Team.

Photo by Kampus Productions from Pexels.

Learning activity (10 mins)

Complete the following multiple-choice quiz. Check your answer by clicking the blue ‘Check’ box below before clicking the arrow across to go to the next question.

Read the ‘COVID-19’ section of the persona of Jarrod and consider the questions below:

Do you feel Jarrod would require referral to other services?

Which other services might you refer Jarrod to?

 

 

Assessment

Assessment and the use of outcome measures are important to help determine whether a specific physiotherapy intervention is appropriate and its effectiveness, once implemented, as part of the overall management of the patient. Currently there are no tests or tools that have been recommended to confirm the diagnosis of Long COVID^[46][47][48]. Patients with concerning red flags, particularly if sinister pathology is suspected, should be referred onwards in a timely fashion. The goal of the patient interview should be to identify the severity of any symptoms and the impact these have on the quality of life and daily activities for the individual^[49]. Various screening and assessment tools may be used to assist in this process. In addition, a symptom-based objective assessment should be undertaken where indicated, noting that once again there is no "one size fits all" set of outcome measure or tests for people experiencing Long COVID due to the wide and varying symptoms and their severity^[50].

It has been suggested that physiotherapists should screen patients at various time points across the continuum of care (whether they were initially managed in hospital or the community) ^[51] so that patients with Long COVID may be identified early and referred for appropriate and timely follow-up.

General assessment

General assessment may include the following:

There are few Long COVID specific outcome measures and the use of patient-reported outcome measures developed for other conditions may not be applicable or relevant when applied to those with Long COVID^[54]. There is a clear need for Long COVID specific tools to be developed and tested. The following tools are currently being used in Long COVID research or within Australian Long COVID clinics.

Cardiorespiratory screening tools

Modified Medical Research Council (mMRC) Dyspnoea Scale
(Brompton) Breathing Pattern Assessment Tool (BPAT)
Nijmegen questionnaire

Functional and exercise capacity tests

It is important to note, when considering functional or exercise capacity tests, that physical exertion may significantly exacerbate symptoms in some people experiencing Long COVID. Clinical judgement should be used as these tests may not be suitable for all but may offer a useful baseline measure^[55].

1-minute Sit-To-Stand Test (1STST)
2-Minute Walk Test (2MWT)
Timed Up and Go Test (TUG)
10-Meter Walk Test (10MWT)
6-Minute Walk Test (6MWT)
Cardiopulmonary Exercise Test (CPET)
Tinetti Gait and Balance Assessment Tool

Quality of life

EuroQOL EQ-5D-5L
WHODAS 2.0

Psychosocial

Generalised Anxiety Disorder-7 (GAD-7)
Depression Anxiety and Stress Scale (DASS-21) 
Hospital Anxiety and Depression Scale (HADS)

Other

Fatigue Severity Scale (FSS)

DePaul Post-Exertional Malaise Questionnaire
Fatigue Scale for Motor and Cognitive Functions
Functional Assessment of Chronic Illness Therapy – Fatigue Scale (FACIT-F)
Brief Questionnaire to Screen for Post-Exertional Symptom Exacerbation (PESE)

Putting it all together

A proposed surveillance model for use by physiotherapists is presented in the figure below and includes three distinct and scaffolded sections to ensure a comprehensive assessment: a rapid screening, a general assessment and specific assessments that recommend various tools and parameters to aid treatment and management planning^[56]. Rapid screening is designed to initially exclude new acute infection with SARS-CoV-2, noting that people experiencing Long COVID may otherwise answer yes to this question as they may be experiencing symptoms attributable to COVID-19, but this will not necessarily require onwards referral. It is important that the line of questioning within this section also details the patient's symptoms and how these symptoms behave over time. Most importantly, there must be a clear discussion around the goals of physiotherapy treatment. In regard to general assessment in an outpatient setting, auscultation is unlikely to provide any additional information to the patient's overall picture and thus is generally not necessary to perform. Finally, referral to a pulmonary rehabilitation program is typically based on symptoms and functional limitations rather than solely based on impaired spirometry findings. The suggested treatments shown in the grey shaded boxes are just that - suggestions.

 

Learning activity (20 mins)

Considering the persona of Jarrod, outline your assessment plan.

Which screening tools might you use for Jarrod and why?

Exercise-based rehabilitation for Long COVID

Physiotherapy and exercise-based rehabilitation are traditionally considered fundamental to recovery following illness^[57]. However, the evidence to guide best practice physiotherapy management in people experiencing Long COVID remains unclear^[58][59][60].

Physiotherapists, with their known expertise in movement, function, and rehabilitation ^[61], play a vital role in helping individuals regain physical function, alleviate symptoms, and improve their overall quality of life^[62]. People experiencing Long COVID who have a reduced physical capacity and associated symptoms should be considered for referral to exercise-based rehabilitation^[63].

Exercise-based rehabilitation for Long COVID should encompass a tailored program of physical activity that addresses the unique needs and limitations of each individual^{[64][65][66][67]}. Rehabilitation programs may include a combination of education^[68] (including pacing, pain management, self-management among others), aerobic and resistance training^{[69][70][71][72]}.

Physiotherapists play an important role in ensuring the safety and effectiveness of the exercise program, as well as making appropriate modifications based on the individual symptomatology and progress of the patient^[73].

Precautions and contraindications to exercise; an overview

Precautions and contraindications to exercise-based rehabilitation in Long COVID should be considered to ensure the safety and well-being of individuals. While exercise is considered to be generally beneficial, people living with Long COVID may experience symptom exacerbation (i.e., if Post Exertional Symptom Exacerbation or PESE is present) or reduction in their current levels of participation if the unique characteristics of Long COVID are not considered^[74].

Important - RED flags for rehabilitation

As per the WHO guidelines^[75], assessment, further investigation and management of patients with complications related to their COVID-19 acute infection, including significant cardiac impairment (which may present as: chest pain, palpitations or an altered resting heart rate >100bpm^[76]), or respiratory desaturation below recommended parameters (<94%), is strongly recommended prior to the commencement of a rehabilitation program to rule out potentially life-threatening complications.

Whilst there is not a set list of tests or investigations for red flags, thorough assessment and an understanding of the person experiencing Long COVID symptoms and their patterns will assist in minimising risk when commencing exercise-based rehabilitation.

Contraindications

There are no specific contraindications to commencing supervised exercise-based rehabilitation for people experiencing Long COVID provided any reported/observed red flags for safe exercise have been investigated and addressed^[77][78].

Precautions

Symptom monitoring

People with Long COVID may experience fluctuating symptoms resembling those found in other post-viral syndromes such as Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS)^[79].

Symptoms and response to exercise should be monitored closely during, immediately after and in the days following exercise therapy^[80][81]. A symptom or activity diary may be a useful tool to assist in this process - click here for a downloadable diary template.

If, despite the use of pacing/gradual progression/loading, the exercise consistently exacerbates symptoms and results in prolonged worsening of overall health and wellbeing, it may be necessary to reassess the exercise program and consider alternative approaches.

Exertional oxygen desaturation and breathlessness

Physical activity increases oxygen demand, and when significant exertional oxygen desaturation is present, commencing exercise-based rehabilitation should be undertaken with caution. Whilst rare, some patients may develop long-term cardiac and pulmonary complications after an acute COVID-19 infection^[82] which may inhibit their ability to participate in exercise. Referral to a Pulmonary Rehabilitation program and/or a Respiratory Physiotherapist should be considered for patients presenting with symptoms of Post-COVID lung disease as, in these cases, it may not be possible to prevent exertional desaturation.

Symptom titrated physical activity^[83] may be considered within a rehabilitation program where exertional oxygen desaturation is present^[84].

Breathing Pattern Disorders (BPD) including hyperventilation syndrome may be present for some people experiencing Long COVID even if no exertional desaturation is present^[85]. Additionally, many patients may experience breathlessness without desaturation and no evidence of breathing pattern disorders. Breathlessness may result due to prolonged reduced participation and resultant deconditioning. Exercise-based rehabilitation aims to teach people experiencing breathlessness that these sensations are normal, and to give them tools and strategies to assist in self-management.

During exercise rehabilitation sessions, oxygen saturation and dyspnoea symptoms should be monitored throughout using established criteria and outcome measures^[86][87].

Important - When to reduce exercise intensity

The criteria for reduction in intensity and/or ceasing exercise^[88][89]:

• A drop in SpO₂ of > 3-4% from baseline measurement^[90]
• SpO₂ < 90%
  
• Modified Borg Dyspnoea Scale ≥ 6
  
• Shortness of breath with no relief after rest
  
• Chest pain or tightness
  
• Dizziness
  
• Headache
  
• Blurred vision
  
• Palpitation
  
• Tachycardia
  
• Syncope

Heart rate and exercise

Cardiac impairment following COVID-19 infection has been well documented in the literature^{[91][92][93][94]}. Exercise restrictions are recommended in the presence of acute cardiac conditions (e.g., acute myocarditis) because exercise can increase the risk of mortality and morbidity^[95].

There is a potential for the delayed development of cardiac dysfunction in people experiencing Long COVID^[96]. Any changes to cardiac signs and symptoms during or after exercise warrants further clinical assessment and/or investigation^[97][98].

Important - Signs / symptoms of suspected cardiac impairment ^[99][100]

• Chest pain
• Difficulty breathing
  
• High resting or exertional heart rate
  
• Increased respiratory rate
  
• Reduced oxygen saturation
  
• Palpitations
  
• Reduced exercise tolerance

There is currently no consensus on recommended heart rate parameters for exercise-based rehabilitation in patients living with Long COVID.

Key message

It is important for individuals experiencing Long COVID to work closely with their healthcare team, to determine appropriate exercise guidelines and make necessary adjustments based on their individual circumstances and symptomatology.

Exercise-based rehabilitation should be a slow and careful process respecting patient symptoms and response to the exercise program.

Post-Exertional Symptom Exacerbation (PESE)

PESE is a phenomenon characterized by the triggering or worsening of symptoms following minimal physical, emotional, social or cognitive exertion^[101][102]. Symptoms may worsen 12 to 72 hours following activity and may last for days or weeks^[103][104]. The severity and duration of PESE can vary widely among individuals. PESE has been associated with other disabling conditions such as Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS)^[105]. One international study that surveyed people seven months after a suspected or confirmed COVID-19 infection, found that 89.1% of the respondents reported either physical or mental post-exertional fatigue malaise^[106].

“If I don’t get this right, I will crash as soon as I get back to work…”
(Jarrod, 42year old)

PESE can manifest as increased fatigue, exercise intolerance, pain, cognitive dysfunction or ‘brain fog’, sleep disturbances or general malaise^[107]. Patients with PESE may report a reduced capacity to work or study, alongside negative effects on physical functioning, exercise tolerance and social activity^[108]. Patients may often describe experiencing a ‘crash’ after activity if symptom exacerbation is experienced over a longer timeframe^[109].

Symptom stabilisation should be the initial aim^[110][111].

Important - Graded exercise

Graded exercise approaches and fixed activity prescription should not be used in patients experiencing PESE^[112][113]. Activity and exercise prescription should instead be titrated to the individual’s symptoms. The “Stop. Rest. Pace” activity management message along with heart rate monitoring may assist patients with PESE to self-manage with the support of their healthcare provider/s^[114].

Pacing and activity management

Pacing involves employing a range of strategies to avoid both over- and under-exertion, rather than being a form of avoidance behaviour^[115][116]. Evidence for the use of pacing and activity modification as a self-management strategy in people experiencing Long COVID and PESE is limited^[117][118].

Important - Pacing theories

The spoon theory

The Spoon Theory illustrates the limited energy reserves individuals with chronic conditions possess by using spoons as a metaphorical representation of units of energy. Each activity throughout the day "costs" a certain number of spoons, depleting the available energy pool. Once spoons have been used, the person is more likely to experience fatigue or symptom exacerbation. Managing daily tasks becomes a matter of rationing and carefully prioritising spoon expenditure to prevent overexertion and maintain the ability to participate in activities. This theory was developed by people with chronic disease and disability as a way of describing their experience.

For further information,  visit 'The Spoon Theory' written by Christine Miserandino. Christine lives with lupus, and the theory is based on her lived experience of managing this condition.

The energy envelope theory^[119]

This theory proposes that individuals with limited energy resources can manage their well-being by recognising their perceived energy limits. By pacing activities, avoiding overexertion, and balancing rest, they aim to stay within their 'energy envelope'. This in turn aims to minimise symptoms and enhance overall functioning.

For further information, visit 'Finding your Envelope' by Bruce Campbell

Pacing strategies may include^[120][121]:

Heart Rate (HR) monitoring

In ME/CFS HR during exercise is encouraged to be kept within the 'energy envelope' (i.e., below the anaerobic threshold), as breaching this threshold may trigger PESE)^[122]. This may be relevant for those individuals with Long COVID and PESE. HR monitoring can be used to guide working within one’s 'energy envelope', thus ensuring that overall energy expenditure is less likely to result in PESE.

Useful guides to calculate appropriate resting HR and HR that indicates the anaerobic threshold can be found here;

Emerge Australia Pacing with a heart rate monitor (Factsheet)

Workwell Foundation Heart Rate Monitor (Factsheet)

Physio For Me Heart Rate Monitoring (Website)

Education and supported self-management

Education regarding self-management strategies is important for patients experiencing PESE^[123]. Physiotherapists should support self-care strategies and adaptive coping mechanisms by providing information and resources about PESE. This is an important part of the management as appropriate education empowers individuals to self-monitor and make informed decisions about their ongoing care, health and well-being.

Autonomic dysfunction

Autonomic dysfunction, also known as Autonomic Nervous System (ANS) dysfunction or dysautonomia, refers to disruption or impairment in the normal functioning of the ANS^[124]. The ANS is responsible for regulating and controlling involuntary bodily functions, such as heart rate, blood pressure, gastrointestinal motility, respiratory rate and temperature regulation^{[125][126][127]}. It consists of two main branches: the sympathetic nervous system and the parasympathetic nervous system.

When autonomic dysfunction occurs, it can disrupt the balance between these two branches, leading to a range of symptoms and issues. Due to the ANS role in regulating blood flow and therefore oxygen delivery to muscles, individuals with autonomic dysfunction might experience fatigue and exercise intolerance, along with other symptoms such as breathlessness, chest pain, palpitations and presyncope^[128].

Autonomic dysfunction encapsulates a broader spectrum of dysregulation within the ANS, affecting various physiological functions^[129].

 

Key message - Autonomic dysfunction

If you suspect either yourself or someone you know is experiencing autonomic dysfunction, it's important to consult a medical professional for an accurate diagnosis and management plan.

Orthostatic intolerance

Orthostatic intolerance occurs due to an abnormal autonomic response to postural change^[130]. Patients can present with either resting or postural hypotension and/or tachycardia^[131][132]. The term orthostatic intolerance may be used when objective tests have been unable to confirm a diagnosis of the common autonomic disorders^[133].

Postural Orthostatic Tachycardia Syndrome (POTS)

POTS is considered a disorder of the ANS that is associated with tachycardia upon standing^[134].

It is clinically defined as^[135][136]:

• a HR increase of ≥ 30 bpm within 10 minutes of standing up without significant hypotension or
• HR >120 bpm for 10 minutes on standing without significant hypotension

Self-management and exercise

Whilst limited evidence exists to manage autonomic dysfunction for people living with Long COVID, education and exercise have been recommended as part of the management^[137][138].

Education should include identification of symptom aggravating and easing factors, as well as including instruction on counterpressure maneuverers such as crossing the legs while standing^[139]. Other education for self-management includes (but is not limited to):^[140]

 

Autonomic Conditioning Therapy (ACT)

Autonomic conditioning therapy or ACT is one rehabilitation protocol that has been shown to improve fatigue in people experiencing Long COVID^[141].

ACT involves participation in a supervised, gradual, symptom-oriented exercise program consisting of three phases of rehabilitation^[142]:

Autonomic Conditioning Therapy Program^[143]

PHASE 1 Phase 1A: Supine active ROM exercises (over minimum of 2 weeks) - AROM knee flexion heel slides - AROM hip abduction - SLR - Hip bridging Performed bilaterally over 30second intervals at an RPE 2/10 on modified Borg scale Recovery breathing (4 sec inhale / 6 sec exhale) between sets Phase 1B: Upright exercise - Seated hip adduction ball squeeze - Seated AROM hip flexion marches - Seated concentric quadriceps long arc - Side-lying hip abduction clamshells - Modified (high kneeling) plank - Continue SLR and bridging exercise from phase 1A 2x sets of 10 reps each exercise, plank 2x 10sec holds

PHASE 2 Phase 2A: Progressive submaximal aerobic exercises (over 4 weeks) - overground walking intervals Week 1: 5x 1 minute intervals progressing to Week 4: 5x 90second intervals Goal to complete total of 6 minutes aerobic training time Phase 2B: Continue progression of submaximal aerobic training (over 4 weeks) Week 1: 3x 2minute intervals progressing to Week 4: 6x 2minute intervals Goal of phase 2B to complete total 12 minutes aerobic training

PHASE 3 Phase 3/ Levine protocol: Progressive and graded aerobic exercise program (over 6 weeks) - 3x sessions / week - Approximately 25-30minutes recumbent bike per session initially - Protocol based on training zones Base pace = 75% age predicted maximum HR and RPE of 13-16 Maximum steady state = RPE 16-18 Recovery pace = RPE 6-12

Importantly, patients participating in an ACT program should be progressively guided through the phases according to their individual symptom responses to the program^[144]. Additionally, patients should be closely monitored for PESE throughout the rehabilitation program.

Key messages

• Exercise-based rehabilitation for those experiencing Long COVID should:
  - be personalised
  - manage expectations
  - be psychologically supportive
  - avoid symptom exacerbation
• Exercise-based rehabilitation should focus on symptom stabilisation in the first instance, as well as strategies to sustain patient function without exacerbating symptoms^[145].
• Physiotherapists can guide the rehabilitation pathway of those experiencing Long COVID, by providing carefully designed programs tailored to the individual, that balance activity with adequate rest^[146].
• Consistent symptom monitoring is a vital component of exercise-based rehabilitation for patients experiencing Long COVID and should be incorporated before, during and after any exercise or physical activity.

 

Learning activity (30 mins)

Read the persona of Jarrod.

Jarrod’s goals (in no particular order) are to:

• Return to work as a painter and decorator or in a related job.
• Feel less pain and stiffness in his body.
• Get back to completing all his activities for himself and no longer rely on others.
• Spend more time with his kids, including looking after them on his own.
• Get back into regularly riding, running and hiking to reconnect with nature.

1.       Considering Jarrod and his description of symptoms, what are the key safety concerns to consider when prescribing an exercise program for him?

Use the padlet to record your answers. Remember that this is a public board, and please do not include any identifying information. This padlet is best viewed in full-screen mode.

Read the following open-access article - Muscle abnormalities worsen after post-exertional malaise in long COVID by Appelman et al.

2.       Write an outline for an exercise program for Jarrod taking into account his goals, symptoms and the potential underlying pathophysiology of his condition. Include how you might modify exercises for him given his presenting symptoms, how exercise may be progressed according to his symptoms and what factors might indicate a need to cease the exercise-based rehabilitation program.

Other physiotherapy treatment/s for Long COVID

In general terms, established symptom management approaches are recommended for people with Long COVID, and as such, physiotherapists should consult existing clinical guidelines to guide their management^[147].

Fatigue

Fatigue or exhaustion is commonly reported in those with Long COVID and may be a major barrier to participation to undertaking everyday tasks.

Pacing and energy conservation techniques may be useful tools for those with Long COVID, who experience fatigue.

Symptom titrated physical activity means engaging in physical activities, that may include exercise, only at a level guided by the presence and severity of symptoms, to mitigate exacerbating symptoms.

It is important to exclude the presence of PESE before commencing exercise-based rehabilitation^[148].

For further information related to fatigue and its management please refer to the previous section on PESE.

Pain management

Patients with Long COVID may experience arthralgia which presents as inflammatory type pain in one or more joints, commonly the knees, ankles and/or wrists^[149] as well as myalgia. Musculoskeletal pain as a symptom of Long COVID can be extremely debilitating and have a significant impact on function^[150].

There is currently no evidence supporting specific interventions to manage pain in patients with Long COVID. The WHO^[151] recommends pain education, self-management strategies and physical exercise training (in the absence of PESE) to manage arthralgia, i.e., treatment should be as per standard practice.

If chronic/persistent pain is present, or suspected to develop, referral to a Chronic Pain Clinic should be considered.

Breathing Pattern Disorders (BPD)

Breathing Pattern Disorders (BPD), also known as breathing impairment or Dysfunctional Breathing (DB) can be defined as dyspnoea associated with an abnormal pattern of breathing in the absence of significant cardiopulmonary disease or dyspnoea that is out of proportion to an underlying cause^[152]. BPD (including hyperventilation and dysfunctional breathing) are common in autonomic dysfunction and POTS.

BPD may be present at rest or during physical activity including activities of daily living and exercise^[153][154]. Hyperventilation Syndrome and Periodic Deep Sighing have been described as the more common presentations of BPD in patients with Long COVID^[155].

The main physiotherapy intervention for patients experiencing BPD is breathing re-training, focusing on establishing a nose/diaphragm pattern of breathing and reducing overall ventilation.

Referral to a specialist respiratory physiotherapist should be considered, in order to optimise management of BPD.

 

Learning activity (10 mins)

Read the persona of Jarrod.

What additional physiotherapy treatment options (other than exercise) may be appropriate for Jarrod given his ongoing symptoms?

Are referrals to other health care providers required at this time for Jarrod?

Self-management for Long COVID

It is recommended that self-management for Long COVID be incorporated into the recovery plan^[156].

Self-management for Long COVID is a broad topic that is currently not covered in detail in this chapter. Information to include or provide those with Long COVID include, but are not limited to:

• Physical activity and returning to exercise
• Management of more common presenting symptoms such as breathlessness or persistent pain
• Management of activities of daily living including general advice related to pacing and energy conservation
• Returning to work or study
• General advice related to nutrition and sleep hygiene
• Links to resources to support psychological wellbeing

The NHS Your COVID Recovery website is an example of best practice for supporting self-management of those presenting with milder impairments attributable to Long COVID^[157].

Conclusion

Physiotherapy plays an important role in optimising the recovery of patients with Long COVID. It is important that clinicians regularly reassess the patient's symptoms, their functional progress, and adherence to the recommended self-management strategies. Modification and adjustment of interventions may be required based on each individual's response to increasing their physical activity and/or exercise load.

It cannot be emphasised enough the importance of individualised management for patients with Long COVID. There is no "one-size fits all" approach to addressing the presenting impairments that may be observed in clinical practice. Working collaboratively with the wider multi-disciplinary healthcare team will result in optimal outcomes for each patient.

Whilst the information contained in this chapter is by no means exhaustive, it is designed to provide an overview and highlight key information for physiotherapists working with people diagnosed with Long COVID. Further reading and resources that may be beneficial for both patients and their families as well as health professionals are provided in the links below.

 

Further information

The following links will provide you with additional information about Long COVID from credible sources. These listings are not exhaustive, and you are encouraged to seek out locally relevant information.

General resources for people with Long COVID and their families

• Long COVID Physio - Website
• NHS - Your COVID Recovery - I have or may have long COVID
• Royal Australian College for General Practitioners (RACGP) - Patient resource: Managing post-COVID-19 symptoms
• Peer support groups
  Long COVID Support Australia
  Lung Foundation Australia - COVID recovery support group
• Provincial Health Services Authority (PHSA) - Post-COVID-19 Interdisciplinary Clinical Care Network Resources - Living with Post-COVID symptoms (website)
• Scottish Intercollegiate Guidelines Network (SIGN) - Long COVID; A booklet for people who have signs and symptoms that continue or develop after acute COVID-19
• World Health Organization (WHO)Support for rehabilitation: self-management after COVID-19-related illness
  Post-COVID-19 Condition (factsheet)

Resources for specific symptoms of Long COVID

• Breathing Pattern Disorders
  Would you like to breathe better?
  Breathing dysfunction

• Breathlessness
  Asthma and Lung UK
• Autonomic dysfunction
  Dysautonomia International
• Long COVID and ME/CFS
  Long COVID and ME/CFS are they the same condition?
• Post Exertional Symptom Exacerbation (PESE)
  Advice on energy and symptom management:
  NICE guideline: Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management
  Activity and energy management - pacing
  Emerge Australia Website: Post-Exertional Malaise (PEM)
• Postural Orthostatic Tachycardia Syndrome (POTS)
  PoTS UK

Health care professional resources

• Australian Parliamentary Inquiry into Long COVID

  Sick and tired: Casting a long shadow. Inquiry into Long COVID and Repeated COVID Infections. 

• National Clinical Evidence Taskforce
  Australian guidelines for the clinical care of people with COVID-19
  Care of people after COVID-19 (flowchart)
• National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and Royal College of
  General Practitioners (RCGP)COVID-19 rapid guideline: managing the long-term effects of COVID-19
• The Lancet
  COVID-19 Resource Centre
• Long COVID Physio
  Resources
  Podcast episodes
• Royal Australian College for General Practitioners (RACGP)
  Caring for patients with pos-COVID-19 conditions
• World Health Organization (WHO)
  Clinical management of COVID-19: living guideline
  Post COVID-19 condition