Long-COVID and rehabilitative exercises

Rebecca Zucco

Rebecca Zucco

Clinical Exercise Physiologist

Becky Zucco is a clinical exercise physiologist specializing in COPD and cancer with over 27 years of experience in her field. She has written and developed educational courses for the prevention and management of chronic diseases. She created Project Move, for elementary schools. She is an avid traveler, marathon runner, and mother of three. She understands the powerful effect of movement on the body and mind, and how human behavior can be influenced to achieve significant improvement in health.

Long-COVID and research-based exercise


What exactly is this? What evidence is there that exercise-based interventions make a difference and what is the opportunity for Kinesiologists to offer services?

Kinesiologists play an increasingly important role in health care, helping those with chronic conditions live well during and post-pandemic. However, we need to empower ourselves with the knowledge and skills to be informed and able to meet the needs of patients in society today.

“Research is key to understanding the value of exercise-based interventions for the chronic disease population, and Long-COVID is no exception.” – Becky


A recent study led by Dr. Marla Beauchamp (Canada Research Chair in Mobility, Aging and Chronic Disease and an assistant professor in the School of Rehabilitation Science at McMaster) has found that adults over age 50 who experience mild or moderate COVID-19 are at increased risk of worsening mobility and physical function, even in the absence of hospitalization for the virus.

The findings, which used data from the Canadian Longitudinal Study on Aging (CLSA), highlight the burden of COVID-19 among middle-aged and older adults who are not hospitalized, and suggest that many patients who experience even mild COVID-19 have persistent and troublesome symptoms.

The researchers looked at mobility issues including difficulty getting up from sitting in a chair, ability to walk up and down stairs without assistance and walking two to three neighborhood blocks, as well as changes in participants’ ability to move around the home, engage in housework and physical activity. The research was published on January 12, 2022, in the journal JAMA Network Open. (1)

“Our results showed there was a higher risk for mobility problems in people who were older, had lower income, those with three or more chronic conditions, low physical activity and poorer nutrition,” (2) – Dr. Beauchamp

“However, those factors alone did not account for the mobility problems we observed among people with COVID-19. Rehabilitation strategies need to be developed for adults who avoid hospitalization due to COVID-19 but still need support to restore their mobility and physical function.” (2) – Dr. Beauchamp


    COVID-19 is an infectious disease caused by a virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first reported and identified in 2019 in Wuhan, China. The World Health Organization declared COVID-19 a pandemic on March 11, 2020.

    The virus-causing COVID-19 (SARS-CoV-2) is one of a large class of viruses known as coronaviruses. They are named coronaviruses because corona means “crown” and these viruses have a crown shape on top of the virus when seen under a microscope. Coronaviruses are known to usually cause mild to moderate upper respiratory tract infections but can also be serious and require hospitalization for a significant proportion of the general population, particularly in those with risk factors such as older age and comorbid conditions. (3)

    As of March 15th, 2022, there have been 3,373,339 confirmed cases of COVID-19 and 36,900 deaths in Canada. (4)

    The exact origin of the SARS-CoV-2 virus is unknown although it is suspected to have been transmitted to humans from another animal species. It is the seventh known coronavirus to infect humans. As COVID-19 has spread, variations in the virus have developed that can respond differently to treatment or vaccines and can result in different symptoms. (5) 

    Many countries including Canada have now seen multiple waves of COVID-19 infection driven by decisions to relax public health measures and the development of more infectious variants. (6,7)

    Multiorgan effects of COVID-19 have been documented in most, if not all, body systems including cardiovascular, pulmonary, renal, dermatologic, neurologic, and psychiatric. Multisystem inflammatory syndrome (MIS) and autoimmune conditions can also occur after COVID-19. A wide variety of health effects can persist after the acute illness has resolved (e.g., pulmonary fibrosis, myocarditis). It is unknown how long multiorgan system effects might last and whether or not the effects could lead to chronic health conditions.

    Most people infected with the COVID-19 virus experience mild to moderate respiratory illness and recover without needing treatment or hospitalization. Within 2 to 14 days of becoming infected with COVID-19, the immune system may respond causing symptoms that can include: Fever, cough, shortness of breath, fatigue, sore throat, and loss of smell/taste. (8,9) 


    What is Long-COVID

    Depending upon the severity of symptoms, most individuals recover from COVID-19 within the first 3–4 weeks after contracting the SARS-CoV-2 virus. Yet, a significant number of individuals experience lingering COVID-19 symptoms for weeks and months after this initial or acute phase of the infection.

    People have collectively described these persistent COVID-19 symptoms with terms such as long COVID, “post-acute COVID-19,” or “post-COVID-19.”

    Some of the common symptoms of long COVID include fatigue, breathing difficulties, insomnia, pain, and brain fog. Additionally, post-COVID-19 can impact multiple organ systems including the kidneys, lungs, pancreas, and heart. (11)

    Rehabilitation can be long and difficult. (12,13) 

    WHO Clinical definition

    Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 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. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new-onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time. (11) 


    Benefits of exercise-based rehabilitation

    We know that safe and effective rehabilitation is a fundamental part of recovery from illness and can improve function in people living with a disability.

    The International Guidance on rehabilitation for long COVID is that COVID-19 survivors with a need for rehabilitative intervention at 6-8 weeks following hospital discharge (with multiple treatable traits) should receive a comprehensive rehabilitation program. (11) 

    WHO and CTS recommend the following outcome measures: (11,14)

    • Exercise tolerance (step tests, sit to stand tests)
    • Functional mobility (walking and transfers, TUG)
    • Strength and range of movement (manual muscle testing such as MRC sum or handgrip test)
    • Balance and coordination
    • Dyspnea (e.g., UCSD, SOBQ)
    • Physical function (e.g., short physical performance battery (SPPB))
    • Health-related quality of life (e.g., EQ-5D-5L)
    • Mental health (e.g., Impact of Event Scale)
    • Fatigue (e.g., VAS scale)
    • Return to work items as applicable


    Recommendations for Exercise

    At 6-8 weeks following discharge:

    • Patients with pre-existing/ongoing lung function impairment: comprehensive pulmonary rehabilitation program consistent with established international standards
    • Patients with loss of lower limb muscle mass and/or function: muscle-strengthening program and nutritional support
    • As a consequence of bed rest, individuals are likely to be deconditioned
    • The principles of exercise prescription remain as described for those that have significant deconditioning and breathlessness
    • Survivors of Covid-19 who report fatigue may benefit from an exercise program prescribed using the principles of graded exercise therapy
    • Early mobilization, sitting out of the bed, undertaking sit to stands exercises, standing with support
    • Functional mobility, including for provision of assistive products
    • Muscle stretching and strengthening
    • Physical exercise and fitness – avoid pushing through fatigue, do activity in manageable amounts, keep expectations low, consider energy conservation techniques before and after activities
    • Education, including for fatigue and breathlessness


    Recommendations for Exercise
    Patients with Muscle Weakness (11)  Patients with Lung Impairment (11)  Rehabilitation Recommendations (Stanford Consensus)
    • Start with range of motion exercises, and if tolerated proceed to muscle strengthening against resistance
    • Patients should be guided by symptoms – those with myalgia should avoid strengthening exercises until myalgia resolves
    • For immobile patients with profound weakness consider the daily use of neuromuscular electrical stimulation to address inactivity-induced atrophies in lower-limb muscles


    • PR is recommended
    • Borg 3-4
    • Start lower intensities, especially during the first 6 weeks (3 rather than 4)
    • Consider fatigue – encourage a conservative approach (graded exercise)
    • 20-30 min, 5 days a week (will vary by the patient)
    • Monitor saturation and stop if there is a drop more than 5-10%
    • Warm-up and cool down
    • Inspiratory Muscle Training – can improve breathing by reducing the effort required by the body as it breathes

    •    Rehabilitation plan should be individualized according to patients’ needs taking into consideration their comorbidities

    •    Rehabilitation should be aimed at relieving symptoms of dyspnea, psychological distress, physical function, and quality of life


    Summary of Exercise Prescription

    Education is an equally important component to rehabilitation for long-COVID. Topics should include management of breathlessness and cough; fatigue management (sleep hygiene, pacing strategies and energy conservation); nutritional management; and psychological care (e.g., management of anxiety and depression).


    1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787975
    2. https://healthsci.mcmaster.ca/news-events/news/news-article/2022/01/12/for-people-over-50-even-‘mild’-covid-19-can-result-in-mobility-problems
    3. Guan, W.J., Liang, W.H., Zhao, Y., et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. Eur Respir J (2020).
    4. Government of Canada. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html#a3
    5. https://ipac-canada.org/sars.php
    6. https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html
    7. https://www.cdc.gov/coronavirus/2019-ncov/variants/understanding-variants.html
    8. https://www.who.int/health-topics/coronavirus#tab=tab_1
    9. https://jammi.utpjournals.press/doi/10.3138/jammi-2020-00
    10. Gupta, A., Madhavan, M.V., Sehgal, K. et al. Extrapulmonary manifestations of COVID-19. Nat Med 26, 1017–1032 (2020)
    11. WHO
    12. Jain, Uday. “Effect of COVID-19 on the Organs.” Cureus vol. 12,8 e9540. 3 Aug. 2020
    13. CDC 2021 https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html
    14. CTS (2021). Canadian Thoracic Society position statement on rehabilitation for COVID-19 and implications for pulmonary rehabilitation. https://cts-sct.ca/wp-content/uploads/2021/11/Published-Article-COVID-19-Implications-Pulm-Rehab.pdf
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