The value of physiotherapy input into Long Covid support

Recent figures from the Office of National Statistics reveal 1.5 million people are living with Long Covid in the UK. Being a new condition, there is limited understanding of how it presents and how best to manage, or even recover from it. 

As one patient with Long Covid said: ‘It’s not like I’ve broken my leg. Doctors and others know what to do with a broken leg.’

However, physiotherapists are adaptable and are able to see the bigger picture and, with other healthcare professional groups, have been quick to respond. 

Due to the varied presentation of the condition, a ‘one-size-fits-all’ approach for those living with Long Covid and returning to the workplace is not recommended. This not only refers to the interventions being provided but how they are being provided too. 

Working with fatigue

Fatigue is commonly reported as a symptom of Long Covid and can be hugely debilitating. There is evidence of cardiac injury post Covid-19 infection regardless of the severity of the acute Covid infection and those with Long Covid can present with a disproportionate breathlessness on exertion, inappropriately increased heart rate and chest pain. 

So before providing any kind of physical activity or exercise-based rehabilitation, it is important that risk stratification is completed to screen for cardiac impairment. Any increase in rehabilitation should be accompanied by continued monitoring for cardiac signs. 

A common side effect of fatigue is Post Exertional Symptom Exacerbation (PESE) - an abnormal reaction of the body when too much energy – physical, cognitive or emotional – has been expended. This is important to note because among its symptoms is exercise intolerance. 

In managing fatigue, it is important to reduce the PESE baseline tolerance as once this baseline is raised (from illness, over-expending energy), it takes much less activity to trigger a PESE response. This is not the time to push on through.

Energy management is key in supporting patients with fatigue and often it is very difficult to establish what might be triggering the symptom, as it may stem from physical, cognitive or emotional issues. It is important to remember that fatigue is individual to each person and their own triggers and levels of energy expenditure. 

Planning, pacing and prioritising remain the cornerstones of fatigue management, and physiotherapists, with their background in goal setting and problem solving, can offer valuable guidance in this trickier-than-it-sounds concept. 

Pacing involves breaking down any activity to make it more manageable, interspersed by rest and relaxation. The key aim is for the patient to complete the activity without any exacerbation of symptoms. 

Activity diaries can be useful in establishing patterns in emotional, cognitive and physical activities and their effects on fatigue. This would include sleep patterns and rest. The diaries can be particularly helpful considering that fatigue can occur up to 48 hours post-energy expenditure. Heart rates can be tracked throughout the day with fitness trackers or by patients checking their pulse manually.

It can be challenging to manage and recognise the energy expenditure from emotions and cognitive tasks. However the concept of “energy spoons” or “energy envelopes” is a helpful way for those with fatigue to moderate their energy, and also to explain to others how fatigue works. Essentially, you have enough energy, in the form of “spoons” or an “envelope”, to expend each day. Establishing how much energy activities will take allows the individual to self-monitor and regulate, leading to better management of their fatigue.

All of these fatigue-management strategies promote self-management by self-monitoring and self-regulating.  

Supporting patients with shortness of breath

Those with Long Covid can present with dysfunctional breathing or breathlessness (dyspnoea), debilitating symptoms affecting quality of life, function and wellbeing. As dyspnoea can be caused by cardiac, respiratory or other causes such as anxiety, it is important that cardiac dysfunction and organ damage is properly investigated and discounted before engaging in physiotherapy.

Symptoms commonly seen in those with Long Covid include breathlessness, chest tightness, dizziness and tremor. It should be noted that some of these symptoms can also be associated with other conditions such as Postural Orthostatic Tachycardia Syndrome.

As well as a robust subjective questionnaire, a physiotherapy objective assessment should include, where possible, respiratory rate, auscultation and observing breathing patterns (for example chest wall movement, nasal breathing and inspiration/expiration volume). 

Recognised self-reported questionnaires such as Nijmegan and MRC Dyspnoea Scale are easy to complete and useful in establishing hyperventilation and dyspnoea respectively. 

Physiotherapy treatment would focus on two areas: education and breathing retraining. Education includes the physiology of dysfunctional breathing and breathing control, and a focus on the effects external factors can have, such as mood and lifestyle.

Breathing retraining would include breathing control (nasal breathing, normal respiratory rate, diaphragmatic breathing and inspiratory/expiratory ratio) with the aim being to slowly and progressively increase tolerance of the imposed breathing pattern and rate.

The above are well recognised physiotherapy techniques and are used widely in many respiratory patients to deal with conditions ranging from COPD to asthma. Their impact on Long Covid has, to my knowledge, not been published as of yet, however with many people presenting with symptoms suggestive of dysfunctional breathing, physiotherapy would be a recommended intervention.

It is well recognised that the anxiety (or fear) of breathlessness can augment the perception of breathlessness. Anxiety is reported as a common symptom of Long Covid and understandably so: the fear of what might be combined with multi-layered symptoms. All Long Covid services are encouraged to consider including self-reported anxiety and depression scales such as GAD-7 and PHQ-9 in order to provide appropriate support and education. 

Lessons for physios

Long Covid is most prevalent in the UK in people aged 35 to 69, who live in more deprived areas and have another activity-limiting health condition or disability. Physios are able to provide valuable input into the support of those living with Long Covid. Taking a holistic view, and utilising multi-system skills, we are able to assess, advise and support, not only through recognised physiotherapy skills but also through the use of supported self-management and effective signposting. Long Covid can be debilitating, frustrating and worrying. Whatever our profession, it’s important to acknowledge its impact on the individual and offer considered support based on the current evidence base.