Working in hospitals and helping rehabilitate patients during the COVID-19 pandemic, East Cork chartered physiotherapist Louise O’Hare noticed something very quickly. Some patients weren’t responding to the rehabilitation process in the expected way.

“Normally when you are getting people walking again you are doing progressive exercises and you can have ups and downs, but it’s a fairly linear track,” she says.

“In long COVID – a post-viral illness - what we noticed was that people would have good days and do really great, but this would be followed by three days of being unable to move and they would cycle in and out of this [pattern] all the time.”

Louise also began seeing patients with long COVID in her private practice in East Cork Physiotherapy, Balance & Acupuncture Clinic in Midleton for assessment and a treatment plan.

Many patients, she finds, present with frequent migraine, including vestibular migraine (a form of migraine which affects balance).

“Migraine is a very common long COVID symptom. We are seeing a lot of people who say, ‘I was fine and then two weeks after COVID this kicked off.’”

She has also seen people present with back pain.

“There can be multiple potential causes of pain but what people with long COVID report is that underlying health conditions, like back problems, become more of an issue. This is probably because the body is under stress fighting this post-viral illness and is therefore more susceptible to anything else they have going on and to picking up other viruses as well.”

There are many other symptoms of long COVID– possibly as many as 200- but fatigue is the major one.

Chartered physiotherapist Louise O'Hare in clinic

“It’s very different from feeling tired,” Louise states. “It’s a feeling of extreme exhaustion that can be prompted by things like simply taking a shower, meeting up with friends or trying to read a book. This ‘brain fog’ can affect how you think or read or plan and your ability to work. Even things like planning a meal can require more effort than before. Some even say they are really wiped after meeting up with friends because it is so hard to concentrate on multiple people’s voices at the same time.”

She explains that one of the main reasons people have trouble recovering from COVID is a condition called Post Exertional Symptom Exacerbation (PESE), as happened to patients she saw in hospital and clinic.

“After some kind of exertion your symptoms will feel worse, sometimes immediately, sometimes a couple of days later,” she says.

“You might have had a good day and decide you’re going to go for a really long walk, but then the next day you have what we call a ‘crash period’ where your symptoms are worse and that may take hours or days to recover from.”

Louise, who trains health professionals in the assessment and care of long COVID sufferers, has a major message to get out to those with long COVID, however.

“Early in COVID recovery we don’t want you to do a lot of exercise. Pushing yourself in long COVID is going to set you back, not push you forward,” Louise says. “That’s an important message to get out there.”

Major symptoms:

  • Shortness of breath
  • Chest pain or tightness
  • Dizziness/vertigo
  • Joint/muscle pain
  • Difficulty sleeping
  • Depression and anxiety
  • Physio treatment

    For a chartered physiotherapist getting to know the person’s symptom pattern is the first treatment step.

    “We would get patients to complete an activity diary so that we can get a sense of their energy reserve pattern over a week or two – good periods, bad periods, what brings on the fatigue etc.

    “After that we try to stabilise them, even out the ‘highs and lows’. For a person with long COVID it will give some predictability about what’s happening. You’re no longer going, ‘am I going to have a good day or a bad day?’ and you can start doing things like very gentle exercise. We teach a lot about pacing so that you’re not overdoing it.”

    Breathing exercises

    Physiotherapists can also help those with long COVID by teaching them breathing exercises.

    “Breathlessness can happen for a couple of reasons, either because there has been some damage to the lung tissue itself during the initial virus or because the body is becoming fatigued so quickly,” Louise says.

    “We would teach you breathing exercises that maximise your lung function, which will ultimately build up your exercise tolerance.”

    This can also help solve the problem of maladaptive breathing patterns.

    “Sometimes people, when they experience breathlessness, learn to breathe a very shallow breath i.e. a lot of their breathing is happening right up at the top of their chest,” she says. “In these cases, they are not breathing effectively so we teach them diaphragmatic exercises, taking deeper breaths and getting them using the whole of their lungs.”

    Overall, a chartered physiotherapist’s help includes offering reassurance, educating the person about pacing and teaching breathing exercises in order to help them manage and recover from their illness.

    “We spend a lot of time teaching about the energy reserve, about not allowing yourself to get to the point of fatigue but instead using the Stop, Rest, Pace approach. That’s where, if you feel that you’re getting tired or about to become tired you stop, take complete rest until that feeling has passed and then pace yourself for the next activity.”

    Recovery times can vary

    Recovery from long COVID is possible, but times vary from person to person, she says.

    “It’s very much a journey rather than a simple solution. An American doctor described it as like being on a ship where you’ve several anchors weighing you down. Seeing a chartered physiotherapist that specialises in long COVID care can help [sort some of the symptom ‘anchors’]. They may also recommend referral to other specialists.”

    For physiotherapy it can mean appointments stretched over a period of months. Treatment from GPs may include medication and/or supplements, for example.

    “With long COVID you may not be absorbing nutrients properly from your food so supplements like magnesium, coenzyme q 10 and vitamins B and D are being recommended,” she adds.

    Hospital clinics

    A number of post-acute and long COVID clinics have been opened or are opening at major hospitals across the country, according to the HSE. Demand is currently outstripping capacity. These clinics include respiratory specialists, physiotherapists and occupational therapists as well as psychological and psychiatric services. St Vincent’s University Hospital, for example, is receiving 40-60 long COVID referrals per month at present.

    Tips for managing fatique

    The 4 ps to help you plan

  • Prioritise - what you need to do in the day. E.g. if having a good day and you want to wash the windows, ask is it necessary or ask for help.
  • Plan - your prioritised tasks and your rest time.
  • Pacing - break your tasks into manageable chunks, allowing time for rest.
  • Pleasure - prioritising things you enjoy is important for your recovery.
  • Pacing

  • Your energy reserve is how much energy you have at your baseline.
  • Your “baseline” is what you can do easily on a good day and what you can just do on a bad day.
  • Complete an activity diary to learn how much energy you really have each day.
  • Always aim to have some energy left at the end of each day or after exercise.
  • Don’t keep going until you are tired.
  • Complete your activity diary to also learn your activity and symptoms patterns. Use this to reduce or modify your activity levels so you can avoid “crashes” or PESE (Post Exertional Symptom Exacerbation).
  • Learn your early signs of PESE and STOP, REST and PACE to avoid a “crash”.
  • Learn to rest

  • Rest means no activity and little or no mental stimulation.
  • Activities such as watching TV and scrolling on a phone or tablet can be over stimulating. You may feel that you’re resting but you won’t feel rested afterwards.
  • Learn to say ‘no’.
  • Sleep hygiene tips

  • Avoid screens for one-two hours before bed.
  • Avoid screens in the bedroom.
  • Consider use of ear plugs.
  • Consider use of a sleep mask
  • Aim for a consistent routine and regular sleep times.
  • Reduce caffeine, sugar and alcohol intake.
  • Geraldine

    Geraldine, 53 from Cork, a patient of Louise’s, says: “Before I started physiotherapy, I had breathlessness and tiredness, and I couldn’t walk for 10 minutes. Over four sessions I improved from walking for 10 minutes to being able to walk for 30 minutes without feeling breathless, and was able to go back to my normal activities. I got a world of information to continue to manage it myself.”

    Useful websites

    This international website was set up by physiotherapists who have long COVID themselves.

    This online platform provides support for people with long COVID

    The Irish Society of Chartered Physiotherapists (ISCP) provides useful information about recovery from long COVID.