Recovery Insights Blog | Foundational Rehab

The Challenge of Long COVID

Long COVID presents unique challenges for exercise. Many people experience:

**Post-exertional malaise (PEM):** Symptoms worsen 12-72 hours after activity

**Fatigue:** Profound exhaustion not relieved by rest

**Exercise intolerance:** Symptoms triggered by previously tolerable activity

**Autonomic dysfunction:** Heart rate and blood pressure irregularities

**Brain fog:** Cognitive difficulties

**Breathlessness:** Out of proportion to exertion

The usual advice—"push through it"—can make long COVID worse.

Post-Exertional Malaise (PEM)

PEM is the hallmark symptom. It means:

Activity feels fine in the moment

Hours to days later, symptoms crash

Can last days to weeks

Includes fatigue, pain, cognitive issues, flu-like symptoms

Critical point: PEM means your body can't recover normally from exertion. Pushing through creates setbacks.

The Pacing-First Approach

Before increasing exercise, stabilize your baseline:

1. Track Your Activity

Note all activities (physical, mental, emotional)

Rate symptom levels daily

Identify patterns and triggers

Find your "energy envelope"

2. Stay Within Your Limits

Don't use all available energy

Stop before exhaustion

Break activities into small chunks

Rest between activities

3. Prioritize

Essential activities first

Cut non-essential demands

Delegate when possible

Rest is productive

Heart Rate Monitoring

Many long COVID patients benefit from heart rate pacing:

Find Your Threshold

Note heart rate when symptoms worsen

Often 100-110 bpm triggers symptoms

Some use "anaerobic threshold" testing

Stay Below It

Monitor heart rate during activity

Stop or slow when approaching threshold

Even walking may need modification

Use a heart rate monitor

Sample Limits

Walking: Keep HR under 100-110 bpm

May mean very slow walking

May need seated activities only initially

Gentle Starting Points

When ready to add structured activity (after baseline stability):

Breathing Exercises

Diaphragmatic Breathing

1. Lie on back, knees bent

2. Hand on belly

3. Breathe in—belly rises

4. Breathe out—belly falls

5. 5-10 minutes, 2-3x daily

Box Breathing

1. Inhale 4 seconds

2. Hold 4 seconds

3. Exhale 4 seconds

4. Hold 4 seconds

5. Repeat 5-10 cycles

Gentle Stretching

Bed or floor based

No significant exertion

5-10 minutes

Stop if symptoms increase

Reclined Exercises

Supine Leg Slides

1. Lie on back

2. Slowly slide one heel toward buttock

3. Return

4. 5-10 each leg

Supine Arm Raises

1. Lie on back

2. Slowly raise arms overhead

3. Lower slowly

4. 5-10 repetitions

Gradual Progression

Only progress if:

No PEM from current level

Stable for at least 1-2 weeks

Recovery feels normal

Increase by:

Adding 1-2 minutes

Or adding 1-2 repetitions

Never increase intensity and duration together

Wait 48-72 hours to assess for PEM before progressing

Sample Progression

Week 1-2: Breathing exercises only (5-10 min)

Week 3-4: Add gentle stretching (5 min)

Week 5-6: Add reclined exercises (5 min)

Week 7-8: Seated exercises (5-10 min)

Week 9+: Standing exercises, short walks

Note: This timeline varies enormously. Some need months at each stage.

Exercise Types to Consider

Lowest Demand

Breathing exercises

Gentle stretching (lying down)

Reclined exercises

Low Demand

Seated exercises

Restorative yoga

Tai chi (seated)

Gentle aquatic movement (warm water)

Moderate Demand (Later)

Slow walking (short distances)

Stationary cycling (very low resistance)

Standing exercises

Higher Demand (Much Later, If Ever)

Normal walking

Light resistance training

Swimming

Red Flags: Stop If You Experience

Significant heart rate increase (>20 bpm above resting)

Chest pain or pressure

Severe breathlessness

Dizziness or lightheadedness

Symptoms worsening during exercise

Post-exercise malaise within 48-72 hours

If red flags occur: Return to previous stable level. Consult healthcare provider.

Autonomic Considerations

Many with long COVID have dysautonomia:

Orthostatic intolerance:

Symptoms worsen when upright

Start with reclined exercise

Progress to seated before standing

May need compression garments, extra salt/fluids

Heart rate variability:

HR may spike with minimal exertion

Monitor and respect limits

Beta blockers sometimes helpful (discuss with doctor)

What NOT to Do

Don't "push through" fatigue

Don't follow standard "return to sport" protocols

Don't compare to previous fitness

Don't exercise during a crash

Don't ignore PEM signals

Don't assume graded exercise therapy (GET) is appropriate

Getting Support

Consider working with:

Physicians knowledgeable about long COVID

Physical therapists experienced in post-viral conditions

Occupational therapists for energy management

Long COVID clinics if available

The Bottom Line

Long COVID requires a different approach to exercise:

1. Pacing first, exercise second

2. Find your energy limits

3. Start extremely low

4. Progress extremely slowly

5. Monitor for PEM

6. Setbacks are information, not failure

Recovery is possible, but it requires patience and respecting your body's signals.

Foundational Rehab provides gentle, adaptable programs suitable for fatigue-related conditions.

Long COVID Exercise: How to Safely Return to Activity