Review Physiotherapy management of long COVID in adults 2026 Nygren-Bonnier and Holland

[Andy]

Introduction​

Persistence of symptoms following coronavirus disease 2019 (long COVID) has emerged as a substantial global health challenge, with a cumulative global incidence of over 400 million people.1 Persistent symptoms occur in a substantial proportion of people following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including many who were never hospitalised. Long COVID affects multiple organ systems and commonly presents with fatigue, exertional intolerance, dyspnoea, chronic pain, autonomic dysfunction, cognitive impairments and mental health symptoms. Coexisting conditions such as dysautonomia, postural orthostatic tachycardia syndrome (POTS) and myalgic encephalomyelitis/chronic fatigue syndrome are frequent, contributing to reductions in daily functioning and health-related quality of life.

Rehabilitation is central to the management of long COVID. Examined interventions include exercise-based rehabilitation, aerobic and resistance exercise, respiratory muscle training, energy saving techniques/pacing and multimodal approaches. While evidence suggests potential benefits for physical function, dyspnoea and quality of life, research remains limited and is complicated by the prevalence of post-exertional symptom exacerbation and autonomic dysfunction; conditions that require careful management and individualised rehabilitation strategies.

This review summarises current knowledge on the physiotherapy management and rehabilitation of long COVID and highlights key challenges and priorities for future research and clinical practice.

Open access

 

[Andy]

"Physiotherapy management of post-exertional malaise

Post-exertional malaise (PEM) has emerged as a defining and clinically significant feature of long COVID, characterised by a delayed (12 to 48 hours) and often prolonged worsening of symptoms following even minimal physical, cognitive or emotional effort.46 This phenomenon reflects underlying disturbances across inflammatory, metabolic, autonomic and endocrine systems and represents one of the primary challenges for rehabilitation in this population. Prevalence estimates vary widely across settings, but a systematic review and meta-analysis46 reported a pooled prevalence of 25% in community-based samples with long COVID. This underscores the need for routine screening and severity grading during clinical assessment among patients with long COVID.

Because exertion can trigger substantial symptom relapse, traditional graded exercise therapy is not recommended in individuals with PEM.43,44 Instead, best practice supports a stratified and individualised approach. Patients without PEM may tolerate low-to-moderate intensity aerobic and resistance training within standard deconditioning frameworks.47 For those with mild-to-moderate PEM, rehabilitation should be carefully titrated below the individual’s symptom threshold, using heart rate monitoring, perceived exertion, breathlessness scores and systematic symptom tracking to guide safe progression (Box 1). In cases of severe PEM, pacing and energy saving techniques, similar to approaches used in myalgic encephalomyelitis/chronic fatigue syndrome, form the cornerstone of care, with an explicit avoidance of fixed, incremental training loads.44"

 

[Trish]

Still the assumption that rehab is helpful for all, just needing individualised treatment for those with PEM. And still the assumption that there is such a thing as safe progression, which sounds to me like pacing up, flexible increments etc.

 

[Sean]

Rehabilitation is central to the management of long COVID. Examined interventions include exercise-based rehabilitation, aerobic and resistance exercise, respiratory muscle training, energy saving techniques/pacing and multimodal approaches.​

I see nothing in there about the results from those examinations. Let alone any evidence cited at all that "rehabilitation is central".

 

[Peter T]

This article illustrates confusion about what people mean when they use the term rehabilitation. The authors are using Rehabilitation to mean both what the lay person understands by the word rehabilitation and also to mean ‘what Rehabilitation specialist do’, which includes other things amongst which is explaining the impact of your condition/disability and finding ways to adapt to it. Unfortunately they do not make these distinctions clear and do not have research to back up the distinct components.

I have previously threatened a thread on this issue, but not yet sorted what I want to say. However there are aspects of what is called ‘rehabilitation’ that are potentially useful, including explaining what an individual’s condition involves, that there is no evidenced treatments, discussion about when symptoms need to be referred back for further medical assessment, discussion of pacing, etc. However, although some like @PhysiosforME have grasped this distinction, it is likely that most current rehabilitation professionals may not be the best people to do this, certainly not if the follow materials put out by BACME.

 

[rvallee]

Rehabilitation is central to the management of long COVID. Examined interventions include exercise-based rehabilitation, aerobic and resistance exercise, respiratory muscle training, energy saving techniques/pacing and multimodal approaches.

Human slop.

While evidence suggests potential benefits for physical function, dyspnoea and quality of life, research remains limited and is complicated by the prevalence of post-exertional symptom exacerbation and autonomic dysfunction; conditions that require careful management and individualised rehabilitation strategies.

What do they even mean by this about researching being limited? How much is enough research? It's been decades since there has been nothing left to try, because all of this is simple, it just doesn't work. What is the stop function here, when people decide "OK, we tried everything, it's time to stop"? Because if they don't have that, and they clearly don't, then this is just an infinite loop. PACE was supposed to be the "definitive trial" and it's been 15 years since it ended and it's still going like it never even happened.

The "complications" they put out here are literally everything, they are literally equivalent to "if we could cure all cancers, then we could cure all cancers, so just do that".

It's not serious to start with the assumption that this should work, and it's undeniably the case, there is simply zero consideration for the possibility that this is a dead-end. There is simply no historical equivalent of professionals failing so badly at their job with so much available to them to do better.

The rationale underpinning rehabilitation in long COVID is that exercise-based interventions may directly address the physiological deficits that underpin persistent symptoms

This is false. It is no such thing, this is only possible when the physiological deficits are known and it's not the case. They sit on a throne of lies.

Randomised controlled trials (RCTs) of exercise-based rehabilitation in long COVID have reported substantial improvements in important clinical outcomes; however, results must be interpreted with caution.

It is therefore likely that the current body of evidence overestimates the effect size of exercise-based rehabilitation in long COVID and additional high quality evidence is needed to be confident in the magnitude of benefit.

Those do not follow one another. There is no reason to think the problem is to do with low quality evidence, and there is absolutely nothing that has forced the low quality other than the fact that any high quality assessment simply debunks the whole thing. This call for endless research is total system collapse. There have been decades of this, hundreds of trials, and all they can think of is "more, more, MORE".

 

[Utsikt]

Even more rehabbers that don’t understand that poor methodology can create the appearance of treatment effects that are not there, or even overshadow the negative treatment effect of harmful interventions.

When are people going to wake up to the reality that the current system rewards poor research?

If you have an ineffective treatment, you are incentivised to do a poor study. That way you might get a moderately positive result and a weak recommendation in favour of the treatment.

If you do a good study, you’ll get an appropriate negative result, and a strong recommendation against the treatment.

Therefore, the people with bad treatments are going to continue doing bad research.

If we rather had the integrity to discard poor research all together and discontinue unevidenced treatments, we’d save tremendous amounts of money and avoid so much unnecessary pain and suffering.