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COVID-19 Long-Haulers


Note – Skip to the “musculoskeletal” section below for the exercises/treatments (and to avoid what might be considered the dryer info)!


Much of the information in this article comes from a course about “COVID-19 Long-haulers” from Mary Massery, PT, DPT, DSc, as well as an article by Nalbandian, et al in Nature Medicine.1 The entire world’s experience with a global pandemic of this magnitude is unsettling and fascinating at the same time. It’s interesting to think that virtually no one alive today has experienced a situation like the one we are all in right now. That statement helps me with understanding that our knowledge of this virus and it’s effects are constantly evolving. We knew almost nothing in the beginning and there is still much we don’t understand. New information is coming to light each day which lets us fine tune our theories and treatments, and sometimes means we have to revise our previous theories.

One thing that is becoming abundantly clear is that many folks are left with ongoing symptoms well beyond the two to four weeks of the active infection.  After a brief description of what happens during an acute COVID-19 infection, I’ll discuss the long-term effects that are being seen and what we can do about them from a physical therapy standpoint.  A multifaceted approach to this illness is now confidently recommended, using a combination of such providers as your primary care physician, various specialists, physical therapists, occupational therapists, speech therapists, psychotherapists, nutritionists, body workers, and complimentary medicine practitioners.

Each person’s experience is different and some will require a different combination of those folks than others. In fact, experts are now recommending the creation of follow up specialty clinics for post-acute COVID survivors to address the multitude of issues experienced.

The primary sequence of a COVID-19 attack are:
1. The virus blocks the ACE-2 enzyme receptors (blood pressure regulator) potentially creating hemodynamic instability (abnormal or unstable blood pressure, which can cause inadequate blood flow to your organs).
2. The ACE-2 receptor is located on type-2 pneumocytes, potentially disrupting surfactant production and impairing alveolar gas exchange resulting in dyspnea (shortness of breath).
3. This causes an immune response. In some people, the immune response is excessive, causing hyperinflammation (cytokine storm) and increases the risk of death. The cytokine storm appears to be the major contributor to long-term symptoms.

So far, it appears that 25-30% of people who test positive and have acute symptoms will have long-term symptoms (longer than 12 weeks). I’ll go through the various systems of the body that are commonly effected and the symptoms that arise through these systems. Then I’ll describe treatments, from a physical therapy perspective, that are being shown to be helpful to decrease these symptoms (click on the highlighted links).


– COVID spreads “like wildfire in the lungs” which may explain why pneumonias are more dangerous, harder to treat, and last longer
– Potential irreversible pulmonary fibrosis
– Pneumonias may cause chronic interstitial lung disease
– Potential chronic cardiac damage
– Potential chronic pulmonary vascular abnormalities increasing dangerous pulmonary embolism risk
– POTS (postural orthostatic tachycardia syndrome): Heart rate and blood pressure work together to keep the blood flowing at a healthy pace, no matter what position the body is in. People with POTS can’t coordinate the balancing act of blood vessel squeeze and heart rate response, due to altered autonomic nervous system (involuntary part of your nervous system) regulation. This means the blood pressure can’t be kept steady and stable. When a person stands up after lying or sitting, blood pressure drops and heart rate increases leading to a feeling of light-headedness and uncomfortably high heart rate with possible fainting.


Due to the acute COVID-19 damage, as stated in the “primary sequence of a COVID-19 attack” above, diaphragm weakness and excessive use of the accessory breathing muscles is commonly seen.


1. Diaphragmatic/piston breathing – This is important for regaining normal chest/abdominal pressure and thus core/trunk stability.

2. “4,7,8 breathing” – This is an additional option that can be used as an alternative to or in combination with the above exercise, where you inhale for 4 seconds, hold for 7 seconds, and exhale for 8 seconds.  This breathing technique is mentioned in multiple books by Dr. Andrew Weil.

I typically start off in a comfortable position with eyes closed and breath normally for a minute or two, noticing any areas of tension and softening into those areas.  Then I begin with the 4,7,8, focusing on gradually slowing and increasing the depth of my breathing.  Ujjayi breathing is a form used in yoga that I find to be helpful for slowing the breath.  This entails keeping your mouth closed and  constricting your throat to the point that your breathing makes a rushing noise (think of slowly fogging up a window with your breath, but keeping your mouth closed).  As you inhale, your belly and bottom of your ribcage will expand like an umbrella.  As you exhale, the umbrella will slowly close.

Another key point is to remember to focus on the exhale.  It is common to only be consciously engaged during the inhale, but improving your range of exhale increases the total lung volume and will improve your ability to inhale and provide more oxygenated air to your body.  These slower and deeper breaths stimulate the parasympathetic nervous system, which promotes relaxation and restoration.2

3. “The Breather” (also found on Amazon, etc.) for inspiratory muscle training for endurance.

The diaphragm weakness and excessive use of the breathing accessory muscles (as well as possible lung fibrosis/scarring) can lead to several subsequent problems:


A. Rib cage/spine/shoulder/pelvic mobility problems as well as pain in the neck/shoulders/head and/or pain in the low back


1. MFR (myofascial release) for fascial tightness across the chest from altered breathing mechanics – see the stretches and myofascial trigger point release options below, with the key aspect being the prolonged (2-3+ minutes) holds to release the fascia
2. Exercises (trunk range of motion and stretching) to increase trunk/shoulder mobility:
foam roller for thoracic spine
thoracic/cervical rotation active range of motion
– thoracic spine active range of motion
– pec stretch


Place your elbows in this position or higher, depending on where you feel the best stretch across your chest. Place one foot forward. Tuck your tailbone slightly so as not to extend through your low back. Slowly shift your weight forward through the doorway until you feel a comfortable stretch through your chest.

3. MFR/trigger point release for neck/shoulder/head/low back pain (check out my book Beyond Tape or The Trigger Point Therapy Workbook for detailed pictures of the trigger points and referral patterns):

Upper trapezius and levator scapulae

Hold direct pressure on tight or tender spots for 2-3+ minutes. Notice tenderness in the spot shown or other spots in the area between your shoulder and neck.


Hold direct pressure or tight or tender spots for 2-3+ minutes.


Hold direct pressure on tight or tender spots for 2-3+ minutes. You can also place a tennis (or lacrosse, etc.) ball in this area and lean up against a wall.

Quadratus lumborum and multifidus (low back)

Quadratus lumborum pictured and try slightly closer to the spine for the multifidus. Hold direct pressure on tight or tender spots for 2-3+ minutes.

4. Diaphragmatic/piston breathing


B. Decreased arm and leg strength due to decreased core stability from chest/abdominal pressure alterations


1. Diaphragmatic/piston breathing to normalize chest/abdominal pressures and regain core stability
2. Couple breathing exercises to movement (inhale with trunk extension and raising arms overhead and exhale on the way down)
Progress coupling the diaphragmatic/piston breathing with the movements push (push up or overhead press), pull (row or pull up), squat, and hinge The hinge (or hip hinge or dead lift) is the most commonly confusing exercise of those movements.  Here is another introductory exercise to help with alignment and technique.  For all exercises, use the idea of “blow as you go”, where you are exhaling (blowing) while performing the power aspect of the exercise (going).  Using the squat as an example, inhale on the way down and exhale while pushing back up.

C. Decreased balance due to decreased postural support/core stability from chest/abdominal pressure alterations


1. Diaphragmatic/piston breathing to normalize chest/abdominal pressures and regain core stability
2. Add balance exercises while focusing on piston breathing.


– Skin breakdown due to prolonged bed rest
– Hair loss

GI System

– GERD:  breathing exercises (diaphragmatic/piston) to normalize breathing pattern and chest/abdominal pressures
– Constipation:  breathing exercises (diaphragmatic/piston) to normalize breathing pattern and chest/abdominal pressures


– Brain fog:  Aside from the contributions from the direct viral infection and systemic inflammation, autopsies have shown large bone marrow cells (megakaryocytes) found in the capillaries of brains possibly occluding or restricting blood flow (researchers described it like finding a football stuck in one of the small pipes in your home).
– Fear:  Again, aside from the contributions from the direct viral infection and systemic inflammation, anxiety and depression can be caused by simply not being able to breath freely.    In addition, the fact that none of us, including the medical community, know much about long-term prognosis or rehabilitation/healing progression at this time is unsettling to say the least.  Fortunately there are many folks in the science and medical communities working hard to provide us with more answers.


Stay Strong!


Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my Facebook page and follow me on Instagram for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.


1Nalbandian A, Sehgal K, et al. Post-acute COVID-19 syndrome. Nat Med. 2021 Mar 22.

2Nestor J. (2020)  Breath:  The New Science of a Lost Art.  Riverhead Books.  (p.144)

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