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In it for the Long (COVID) Haul - Physiotherapy Treatment of Long COVID
By: Jeevan Kooner, BSc, MScPT Student


“COVID-19” has become a regular household term in most of our lives. It is known for the detrimental effects it has had worldwide. Most of those infected by the virus will typically feel better within a matter of weeks. However, for some others, it takes much longer than that and can even lead to other symptoms.

In the Embodia course “Treating Long COVID: A Physiotherapy Perspective”, Jessica DeMars shares insight on this new condition and how physiotherapists can best prepare themselves to assess and treat patients living with it.

Follow along as I share the tips and tricks I learned from this course to assessing and treating Long COVID – and let me tell you, it is a tricky one!


Background Information

An important aspect of being a physiotherapist is knowing what you are working with. It is imperative that we educate ourselves on this condition so that we know what to look for in practice.


What is Long COVID?

According to the World Health Organization (WHO), Long COVID is a condition that occurs in an individual with a history of a probable or confirmed case of the SARS CoV-2 infection (better known as, COVID-19).

It typically occurs 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. There are three main clusters of symptoms that may occur as a result: fatigue, shortness of breath, and cognitive decline. However, the condition is not limited to these few findings.


Risk Factors/Cause of Long COVID

Those that experience Long COVID have had a probable or confirmed case of COVID-19 at least 3 months prior to their Long COVID diagnosis. According to the CDC, the following characteristics describe the individuals that are at a higher risk of experiencing Long COVID – however, it is not limited to this population and has been seen in patients of different genders, ages, and levels of health concerns:

  • People who experienced a more severe COVID-19 illness
  • People with underlying health conditions prior to COVID-19
  • People who did not get a COVID-19 vaccine
  • People who experienced multisystem inflammatory syndrome (MIS) during or after COVID-19 illness



Considering the emerging nature of Long COVID, the prevalence of the condition is still not well known. However, a UK study has suggested that 1 in 10 people experience lasting effects of COVID-19 3 months after the onset of their initial COVID-19 symptoms.

This indicates that, following the millions of COVID-19 infections, Long COVID is going to become a more regular concern seen in the clinic.


Signs and Symptoms

Long COVID is being characterized as a multi-symptom disease – there are currently 200 listed symptoms. These all may occur in different combinations and can present in both predictable and unpredictable patterns of flare-ups and remissions. These symptoms may last from a few months to potentially years.

 Prevalence of Long COVID Symptoms

Image source: Goërtz, Y. M. J. et al., 2020


This figure was pulled from research conducted by Goertz et al. (2020), where they followed the recovery of 2113 COVID-19-infected individuals that experienced mild to severe symptoms. The participants reported the symptoms they experienced during the infection, and then again 79 days later at a follow-up. These findings indicate the presence of Long COVID and help healthcare providers know what those experiencing Long COVID are likely to present with.


In the course, Jessica DeMars highlights the most frequent symptoms on the graph that they see in the clinic:

  • Fatigue
  • Dyspnea
  • Chest tightness
  • Cough
  • Pain/burning feeling in lungs


Post Exertional Malaise (PEM)

Complications following COVID-19 were expected to follow the deconditioning model. it was thought that after a few weeks of being “out of commission” with the virus, the inactivity would lead to deconditioning and could be treated accordingly. However, as more and more patients started presenting with Long COVID, it started to become apparent that they were instead experiencing Post Exertional Malaise.

PEM is the worsening of symptoms and decreased function following physical, cognitive, or emotional effort. Typically, immediate symptoms from exercise stress resolve quickly. However, in individuals experiencing PEM, these symptoms may last for hours or even days.

As per Physios for M.E., these are the symptoms to screen for:

  • Activity-induced fatigue (physical or mental)
  • Intermittent and recurring flare of viral symptoms
  • Inability to maintain previous levels of activity
  • Unrefreshing sleep
  • Cognitive problems
  • Orthostatic intolerance


Considering the prevalence of this symptom in the Long COVID population, healthcare practitioners must be aware of it and know how to treat this condition. In physiotherapy, it seems as though exercise is always the answer. However with PEM, that is not the case – in fact, it’s the opposite. For PEM, heavy exercise is not recommended, but rather small bouts of exertion that are gradually increased over time. In other words, if Post Exertional Malaise is suspected, standard rehabilitation practices may be detrimental to the patient.


Patient Perspective

Those affected by Long COVID will likely have a long list of symptoms but a series of normal tests. Before their Long COVID diagnoses, patients have said that when reporting their symptoms to a healthcare practitioner, they were often told that they were just being anxious. This is deeply concerning as it is becoming more known that anxiety is caused by the symptoms, not the other way around. This can lead to a lot of confusion and frustration.

It is important for healthcare practitioners to be good listeners and believe the patients’ experiences. By being aware of what to look out for and what to assess, the patient may be diagnosed and treated sooner.

To learn more about Long COVID and the lived experience described by physiotherapists affected by it, take the online course:

Long COVID and Physiotherapy- Supporting Patient Care and Well-Being



Physiotherapy Assessment

 In the course, Jessica DeMars outlines suggestions from a respiratory-based physiotherapy perspective:

Respiratory Measures

  • Pulse oximetry
  • Respiratory rate
  • Breathing pattern
  • Maximum inspiratory pressure
  • End-tidal CO2


Cardiac Measures

  • Blood pressure
  • Heart rate
  • Heart rate variability



  • Screening for Post Exertional Malaise



  • Mobility, strength
  • 1 minute sit-to-stand, 30 second sit-to-stand
  • Grip strength

*It is not recommended to perform any additional MSK strength and/or function assessments on patients experiencing any form of profound fatigue (i.e. PEM).


Patient-Reported Outcome Measures

Jessica DeMars provides suggestions on some patient-reported outcome measures that can be used to assess the patients with more accuracy.

  • Self-evaluation of breathing questionnaire by R. Courtney
  • Multidimensional Fatigue Inventory by E. Smets, B. Garssen, and B. Bonke
  • DePaul symptom questionnaire for capturing PEM
  • Post-Covid Functional Status flowchart by F. A. Klok et al.


 Patient self-report methods for the Post-COVID-19 Functional Status (PCFS) scale



Clinical Findings

In the course, some of the major respiratory-related findings seen in Long COVID patients were listed as the following:

  • Increased respiratory rate
    • reduced exhale phase
    • reduced heart rate variability
  • Reduced respiratory muscle strength/endurance
  • Reduced end-tidal carbon dioxide (hyperventilation)
  • Apically dominated breathing patterns


Physiotherapy Management

 Long COVID Physiotherapy Management


Respiratory Management

  • Breathing retraining
    • Restore breathing patterns
    • Relaxation
    • Functional breathing
    • Inspiratory muscle training
  • Cough Management
    • Airway clearance techniques
    • Cough control for irritable dry cough



  • Stop, rest, pace
  • Education on pacing and prioritizing
  • Heart rate monitoring



  • Education
  • Guidance
    • Fluid intake
    • Electrolytes
    • Compression pants
    • Exercise if no PEM – supine/resistive
  • Heart rate variability (HRV) training
    • Slow, pace, diaphragm breathing
    • Assist with regulating ANS



  • Pain management
  • Mobility assessment
  • Exercise prescription
    • Slow, paced and monitoring for PEM
    • If PEM – get it contraindicated!



  • Listen
  • Believe
  • Advocate


It is important to remember that the patient is an expert in their own lived experience, so it is vital to listen attentively to what they are saying and believing them. 

Long COVID is a new emerging syndrome that we are learning more about every day. So if a patient asks you something you are unsure about, that’s okay! What is most important is that you validate your patients’ symptoms and experiences, and are honest with them. Let them know that you are unsure, but provide reassurance by working with them to find the best way to help them get better!


Closing Thoughts

Whether we like it or not, Long COVID is a condition that we are going to see a lot more in the clinic. It is so important that healthcare practitioners know what it is and have a solid foundation in how to best assess and treat patients affected by it. Listening to and learning from Jessica DeMar’s expertise in this emerging condition is a great way to start! I highly encourage anyone interested in learning more about Long COVID to take this course.

I hope you found this blog helpful and learned about physiotherapy treatment for Long COVID. I have linked the courses I used for this blog below and have also attached some resources/references that I found useful during my own research. With these tools, we can educate and prepare ourselves for the future. 



Embodia Courses:

Treating Long COVID - A Physiotherapy Perspective

Long COVID and Physiotherapy- Supporting Patient Care and Well-Being




  1. Canadian Physiotherapy Association. (2022, May). Long COVID Resource Page. Physiotherapy.
  2. CDC. (2022, June 17). Post-COVID Conditions. Centers for Disease Control and Prevention.
  3. Courtney, R., & Greenwood, K. (2009). Preliminary investigation of a measure of dysfunctional breathing symptoms: The Self Evaluation of Breathing Questionnaire (SEBQ). International Journal of Osteopathic Medicine, 12, 121–127.
  4. Goërtz, Y. M. J., Van Herck, M., Delbressine, J. M., Vaes, A. W., Meys, R., Machado, F. V. C., Houben-Wilke, S., Burtin, C., Posthuma, R., Franssen, F. M. E., van Loon, N., Hajian, B., Spies, Y., Vijlbrief, H., van ’t Hul, A. J., Janssen, D. J. A., & Spruit, M. A. (2020). Persistent symptoms 3 months after a SARS-CoV-2 infection: The post-COVID-19 syndrome? ERJ Open Research, 6(4), 00542–02020.
  5. Jason, L. (2022). DePaul Symptom Questionnaire-COVID.
  6. Klok, F. A., Boon, G. J. A. M., Barco, S., Endres, M., Geelhoed, J. J. M., Knauss, S., Rezek, S. A., Spruit, M. A., Vehreschild, J., & Siegerink, B. (2020). The Post-COVID-19 Functional Status scale: A tool to measure functional status over time after COVID-19. European Respiratory Journal, 56(1), 2001494.
  7. Smets, E. M. A., Garssen, B., Bonke, B., & De Haes, J. C. J. M. (1995). The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. Journal of Psychosomatic Research, 39 (5), 315–325.

World Physio briefing paper on safer approaches to Long Covid, it may be of help if you haven't already picked this up (



Date written: 31 August 2022
Last update: 31 August 2022

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