Long COVID – persistent symptoms following infection by coronavirus 2 (SARS-CoV-2, COVID-19) – has affected more than 400 million people globally since the virus first appeared in late 2019. The condition is defined by the persistence or emergence of new symptoms, three months after the initial illness, that last for more than two months and cannot be explained by alternative diagnoses.

Long COVID is a multisystem condition that may involve the cardiovascular, respiratory, neurological, endocrine, immune, reproductive and gastrointestinal systems. Clinical symptoms can include fatigue, dyspnoea, reduced physical capacity, post-exertional symptom exacerbation, cognitive impairment, dysautonomia and gastrointestinal disturbances, along with defined conditions such as interstitial lung disease, cardiovascular disease, autoimmune disorders and metabolic dysregulation, and an elevated risk of stress, depression and sleep disorders. Common coexisting conditions include dysautonomia, postural orthostatic tachycardia syndrome and myalgic encephalomyelitis/chronic fatigue syndrome.

Recovery may be gradual or patients may have prolonged, non-resolving symptoms that last for months or years, often with relapses. The evidence currently suggests that long COVID should be considered a spectrum of related conditions, or subtypes, driven by different risk factors and underlying biological pathways. For more than three-quarters of people with long COVID, the condition results in a moderate-to-severe reduction in quality of life, reduced work capacity and elevated healthcare usage over a period of many months or years.

Long COVID care is often multidisciplinary and physiotherapists can play a role in managing many of the symptoms, including through exercise-based rehabilitation and respiratory muscle training. However, there are specific features of long COVID that should be considered when making a management plan, including post-exertional malaise and symptom exacerbation and postural orthostatic tachycardia syndrome.

In their Journal of Physiotherapy Invited Topical Review, Malin Nygren-Bonnier and Anne Holland explore different areas of long COVID management where physiotherapists can play a part and evaluate the current evidence for best practice approaches. These areas include exercise-based rehabilitation, respiratory muscle training and management of post-exertional malaise, breathing pattern disorder, dysfunctional breathing, postural orthostatic tachycardia syndrome and cognitive impairments. They note that physiotherapists are well placed to support self-management for people with long COVID and outline an optimal model of care to ensure that people with long COVID can access the right treatments and support at the right time.

The authors write that there are important gaps in the evidence for physiotherapy management of long COVID, including the need for a better understanding of post-exertional malaise and who will benefit from exercise-based rehabilitation, and better tools for capturing the symptoms and the impact of long COVID. The need for implementation research, education, policy development and knowledge translation is also discussed.

For more information, see the Invited Topical Review in Journal of Physiotherapy (JoP).

This blog is a Physiotherapy Research Foundation (PRF) initiative.

Malin Nygren-Bonnier is an associate professor and a senior lecturer with a combined employment between the Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and the Medical Unit of Occupational Therapy and Physiotherapy at the Karolinska University Hospital, Sweden. Malin’s research focuses on interventions for people with decreased lung function due to COVID and long COVID, neuromuscular disorders, chronic obstructive pulmonary disease and cystic fibrosis, along with preoperative and postoperative rehabilitation.

Anne Holland is professor of physiotherapy and head of respiratory research at Monash University and Alfred Health in Melbourne. Anne’s research program investigates supportive therapies for people with chronic respiratory disease, with a focus on chronic obstructive pulmonary disease and pulmonary fibrosis. Her recent clinical trials have tested new models of pulmonary rehabilitation to improve access and uptake, including low-cost home-based models and telerehabilitation.