In the ever-evolving story of the coronavirus (COVID-19), experts are finding out that symptoms can linger many days, weeks, or even months after the initial viral attack. What’s even scarier is that no one seems to know who will suffer from these prolonged symptoms. 

Generally speaking, researchers think that most people fall into one of two groups when it comes to recovering from COVID-19. The vast majority will have mild cases and recover within two weeks. Those who have severe infections can take anywhere from six weeks to a few months to recover. 

But now, there is growing concern over people who don’t appear to fall into either category. Some estimate that 10-30% of people with COVID-19 will suffer from at least 1-2 prolonged symptoms even months after being infected. This observation is similar to other post-viral syndromes, like the SARS epidemic of 2003 and the Middle East respiratory syndrome (MERS) outbreak in 2012. 

This group of people with lingering symptoms have coined the term “long haulers” for themselves. As more and more people have become vocal about their continued symptoms, there has been a growing recognition of post-acute COVID-19, which is now formally known as Post-Acute Sequelae of SARS-CoV-2 infection (PASC). PASC is also known as COVID Long Haulers, Long COVID, Long Haulers, Long-term COVID-19, or LTC-19.

Learning About COVID-19 Long-Haulers Syndrome
COVID Long Haulers refers to the symptoms that are present more than a month after the initial COVID-19 infection. It has been seen in people of varying ages, regardless of whether the initial infection was mild, moderate, or severe.

As mentioned above, experts estimate about 10-30% of COVID-19 survivors will become COVID Long Haulers. At this point, we don’t know what can predict who will develop long-term symptoms, since a mix of relatively young and healthy individuals are affected, all the way to older, less healthy individuals. As we speak, researchers are working hard to learn more about COVID Long-Haulers Syndrome, and a lot of collaboration amongst large research groups is happening worldwide.

Interestingly, a new study points out that people who have more than five symptoms during the initial COVID-19 infection may be more likely to develop COVID Long Haulers. The symptoms that were most telling are fatigue, headache, hoarseness, muscle pain, and shortness of breath. 

COVID-19 Long-Haulers Symptoms
The most significant symptom seen across the board in COVID Long Haulers is fatigue. People will often report feeling extremely run down with difficulty doing simple tasks, like walking to check the mail or grocery shopping. 

Admittedly, chronic fatigue can be incredibly debilitating, which is one of the reasons why researchers are working so diligently to learn more about COVID-19 Long-Haulers symptoms. Other symptoms associated with COVID Long Haulers include: 

• Shortness of breath
• Cough
• Chest pain
• Difficulty with thinking and concentration (aka “brain fog”)
• Muscle and joint pain
• Headache
• Fever
• Heart palpitations
• Myocarditis
• Kidney problems
• Rash
• Smell and taste problems
• Memory problems
• Anxiety and depression
• Post-traumatic stress

COVID-19 Long-Haulers symptoms can linger for days, weeks, or even months after they initially appear. And unfortunately, it’s uncertain how long it will take for them to resolve. 

Exercising Safely with Long-Haulers Syndrome
If you’re recovering from a mild COVID-19 infection, it’s recommended that you follow a gradual return to activity. Experts in the field suggest using the 50/30/20/10 rule for four weeks before returning to your usual workout routine. 

The 50/30/20/10 Rule suggests that exercise volume (calculated by how much and how often you work out) is reduced by at least 50% for the first week. Then, you are supposed to reduce exercise volume by 30%, 20%, and 10% in the following three weeks. As always, modify this schedule if you don’t feel ready to move on at the end of each week. 

Another reputable source, the English and Scottish Institute of Sport, suggests that you should begin with simple daily activities, like getting dressed or light housework, and walk about half a mile (roughly 1 km) without feeling overly tired. Once you can achieve that, then you can attempt to resume normal workouts.

As soon as you’re ready to start exercising again, light intensity workouts for at least two weeks are strongly encouraged. Activities that qualify as light intensity include household and light gardening, walking, and balance or yoga exercises. Breathing, stretching, and light strengthening workouts are also appropriate. 

Expert tip: Track your exercise intensity by doing the talk test. During light intensity exercise, you should be able to hold a full conversation with a friend without difficulty. As your intensity increases, you may find yourself speaking in short phrases or not at all. 

After you’re able to exercise without shortness of breath or other similar symptoms, you may be ready to move on to more challenging activities such as swimming, jogging, and cycling. Don’t forget to add in exercises for coordination, balance, and flexibility. 

Some tips for getting back into strength training are as follows:

• In the beginning, prioritize whole body, compound movements in your strengthening routine. Focus on bodyweight squats, planks, push-ups, or lunges as opposed to isolated movements like bicep curls or shoulder presses. 
• If you’re struggling to do normal strength workouts, try doing stability exercises instead. These workouts can still be challenging without the stress and strain of other types of exercises. 
• Instead of forcing yourself to do 10 repetitions, use an effort scale to determine how many repetitions you should be doing on a particular day. For example, when using a scale of 0-10, your perceived effort should be around 7-8 before stopping. This scale means that you might be doing different repetitions for each exercise, which is okay for now. 

The length of your workouts should be increased by 10-15 minute intervals before increasing the intensity. Monitor for symptoms even after you’re done exercising, and look for any changes to your breathing rate, depth of breath, energy levels, and mood. If any of these things seem off, it could be a sign that you’re not ready to exercise at that level, and that you may want to seek medical attention. 

Where to Start
These Fitness Blender workouts are perfect for a gradual reintroduction to exercise. 

• Yoga and Pilates
• Low Impact Round 2 (use beginner modifications)
• Beginner Challenge
• Fundamentals Challenge 

You can also try this Pilates combo flow for stability or Kelli’s stretching workout for stress relief. 

Please remember to be kind to your body and your mind as you ease back into your workout routine. If you find yourself experiencing any of the symptoms listed above, contact your primary care provider to determine the next steps. 

Note: For the most up-to-date facts about the coronavirus in the United States, refer to the Centers for Disease Control and Prevention Coronavirus website here. Information for other countries should refer to the World Health Organization’s site here. 

Recent Updates
Since we published the article, there have been some noteworthy updates that are worth sharing: 

• Several pharmaceutical drugs are currently in various phases of clinical trials, and they are aimed at targeting different aspects of COVID Long Haulers. Historically, researchers look to prescribe drugs that are already approved for other conditions, a practice referred to as “off-label” use. Additionally, efforts are being made to develop new medications to address inflammation in the lungs, cells, and postural orthostatic tachycardia syndrome (POTS). 
• The discussion centered around POTS and its link to COVID Long Haulers is gaining momentum. This is due to the fact that people with COVID Long Haulers can develop problems regulating heart rate, blood pressure, digestion, and other involuntary (not under your control) actions. POTS causes your heart rate to dangerously spike, even with something as simple as making a sandwich. The fact that the underlying causes of POTS after being infected with COVID-19 have yet to be discovered is cause for concern, and one that you should be aware of as you slowly begin exercising again.
• POTS is diagnosed by a physician and confirmed by a thorough physical examination, including several measurements of your blood pressure in varying positions. Once diagnosed, you will need to be mindful of triggers, such as moving too quickly, long periods of standing, warm environments, and dehydration. Exercise is recommended, but the structure and parameters should be individualized for your needs. 
   

Written for Fitness Blender by Kayla C, PT, DPT
Board-Certified Neurological Clinical Specialist

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health provider regarding any questions you may have about a medical condition or health objectives.

References

Metzl, J. D., McElheny, K., Robinson, J. N., Scott, D. A., Sutton, K. M., & Toresdahl, B. G. (2020). Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete. HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 16(Suppl 1), 1–6. Advance online publication. https://doi.org/10.1007/s11420-020-09777-1

Salman, D., Vishnubala, D., Le Feuvre, P., Beaney, T., Korgaonkar, J., Majeed, A., & McGregor, A. H. (2021). Returning to physical activity after covid-19. BMJ (Clinical research ed.), 372, m4721. https://doi.org/10.1136/bmj.m4721

Rubin R. As Their Numbers Grow, COVID-19 “Long Haulers” Stump Experts. JAMA. 2020;324(14):1381–1383. doi:10.1001/jama.2020.17709

Sudre, C.H., Murray, B., Varsavsky, T. et al. Attributes and predictors of long COVID. Nat Med 27, 626–631 (2021). https://doi.org/10.1038/s41591-021-01292-y 

Logue, J. K., Franko, N. M., McCulloch, D. J., McDonald, D., Magedson, A., Wolf, C. R., & Chu, H. Y. (2021). Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA network open, 4(2), e210830. https://doi.org/10.1001/jamanetworkopen.2021.0830

Bellan, M., Soddu, D., Balbo, P. E., Baricich, A., Zeppegno, P., Avanzi, G. C., Baldon, G., Bartolomei, G., Battaglia, M., Battistini, S., Binda, V., Borg, M., Cantaluppi, V., Castello, L. M., Clivati, E., Cisari, C., Costanzo, M., Croce, A., Cuneo, D., De Benedittis, C., … Pirisi, M. (2021). Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four Months After Hospital Discharge. JAMA network open, 4(1), e2036142. https://doi.org/10.1001/jamanetworkopen.2020.36142