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Long COVID

Original Editor - Darren Brown Top Contributors - Darren Brown, Jess Bell, Olajumoke Ogunleye, Kim Jackson, Shwe Shwe U Marma, Robin Tacchetti, Stacy Schiurring, Tarina van der Stockt, Lucinda hampton, Candace Goh and Chelsea Mclene 

Introduction

Long COVID describes symptoms and health problems that continue or develop after infection with SARS-CoV-2, the virus that causes COVID-19. The name "Long COVID" was created by people living with the condition. They chose it for two reasons: it does not assume what causes the condition or how long it will last, both of which were unknown, and it makes clear that a "mild" initial infection can still be followed by a long and disabling illness.[1]

Other terms in use include post-COVID-19 condition [2] and post-COVID-19 syndrome.[3]

Definitions

Several definitions are in use. Rehabilitation professionals are likely to meet all three below, and it helps to know how they differ.

Term used Definition Key features Source
  • Ongoing symptomatic COVID-19
  • Post-COVID-19 syndrome
  • "Long COVID" is used to describe both
 Ongoing symptomatic COVID-19: signs and symptoms from 4 to 12 weeks after acute infection. Post-COVID-19 syndrome: signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.
  • Time-based
  • Requires exclusion of alternative diagnoses
 A joint guideline from the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network and the Royal College of General Practitioners. (2020; last updated 2024)[4]
Post COVID-19 condition Occurs in people with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from onset, with symptoms lasting at least 2 months that cannot be explained by an alternative diagnosis. Symptoms may be new or persist from the acute illness, and may fluctuate or relapse.
  • Internationally used
  • A separate definition exists for children and adolescents[2]
 World Health Organization, 2021[5]
Long COVID An infection-associated chronic condition that occurs after SARS-CoV-2 infection and is present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state affecting one or more organ systems.
  • Can follow asymptomatic, mild or severe infection
  • Laboratory confirmation of infection is not required
  • Can be diagnosed alongside other conditions
 US National Academies of Sciences, Engineering, and Medicine (NASEM), 2024[6]

The three definitions share core features: all describe symptoms that persist or emerge after SARS-CoV-2 infection, use a threshold of around 3 months, do not require a positive test, and recognise that symptoms can affect several body systems and fluctuate. The main difference is that NICE and the WHO require other diagnoses to be excluded, while NASEM allows Long COVID to coexist with other conditions.[4][5][6]

The NASEM definition frames Long COVID as one of a wider group of infection-associated chronic conditions, which also includes myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).[6]

Epidemiology

Prevalence

Estimates vary widely because studies use different definitions, time points and methods (often self-report).

Globally, the World Health Organization estimates that around 6 in every 100 people who have COVID-19 develop post-COVID-19 condition, and that the chance appears lower now than earlier in the pandemic.[2] A 2026 review estimates that more than 400 million people worldwide have been affected, with annual economic costs that may exceed US$1 trillion.[7] In England, 4.2% of respondents to the 2025 GP Patient Survey described themselves as having Long COVID.[8] In the United States, 2022 national survey data showed that 7.2% of adults had ever experienced Long COVID, including 20.9% of those who reported a previous COVID-19 infection.[9]

Risk factors

Risk is higher with female sex, age over 40, higher body mass index, smoking, comorbidities and severe acute illness requiring hospital or intensive care, and lower after two doses of vaccination.[10] Among women, risk is greatest between 40 and 55 years.[11] Long COVID can follow infection of any severity,[6] although the risk appears lower after Omicron-era infection.[2]

Course and trajectory

The course of Long COVID varies widely, and symptoms may fluctuate or relapse over time.[5]

In a Swiss cohort mostly infected before vaccination, 17.2% had not recovered at 24 months, and around 1 in 10 reported worsening or alternating health.[12] In the US RECOVER (Researching COVID to Enhance Recovery) cohort, mostly infected in the Omicron era, 46% of those with Long COVID at 3 months had persistent symptoms over 15 months of follow-up, while 14% of participants developed increasing symptoms after initially not meeting the threshold.[13]

Clinical implication: many people improve, but a substantial minority have persistent, fluctuating or worsening symptoms. Rehabilitation plans should anticipate relapses and long-term needs, not assume steady recovery.

Body Systems Affected

Long COVID can affect any body system, and more than 200 symptoms have been reported.[14] Symptoms usually occur in clusters that overlap and change over time.[15]

The table summarises common symptoms by system.[15][16][17]

System Common symptoms and conditions
Generalised
  • Fatigue
  • Post-exertional malaise (PEM)
  • Pain
  • Fever
Neurological and cognitive
  • Cognitive impairment ("brain fog"), including problems with memory and concentration
  • Headache
  • Sleep disturbance
  • Dizziness
  • Peripheral neuropathy symptoms
Autonomic Orthostatic intolerance, including postural orthostatic tachycardia syndrome (PoTS)
Respiratory
  • Breathlessness
  • Cough
  • Breathing pattern disorder
Cardiovascular
  • Chest tightness or pain
  • Palpitations
  • Tachycardia
Musculoskeletal
  • Joint and muscle pain
  • Muscle weakness
  • Reduced exercise tolerance
Gastrointestinal
  • Abdominal pain
  • Nausea
  • Diarrhoea
  • Reduced appetite
Psychological
  • Anxiety
  • Depression
  • Symptoms of post-traumatic stress
Ear, nose and throat
  • Loss of or change in smell and taste
  • Tinnitus
  • Earache
  • Sore throat
Sexual health
  • Reduced libido
  • Erectile dysfunction
  • Ejaculation difficulty
Skin and hair
  • Rashes; hair loss

The following optional 20-minute video provides an overview of Long COVID and discusses the complex nature of potential symptoms these patients may have.

[18]

Mechanism of Injury / Pathological Process

The cause of Long COVID is not fully understood, and it is likely that several interacting mechanisms contribute, varying between people. There are currently no curative treatments and no validated diagnostic biomarkers.[7]

Several leading hypotheses have been proposed:[7]

  1. Immune dysregulation and autoimmunity involve persistent changes in immune cells and cytokines, and autoantibodies, including some that target receptors involved in autonomic function.
  2. Viral persistence and reactivation are suggested by SARS-CoV-2 RNA or proteins detected in tissues months after infection, and by reactivation of latent viruses such as Epstein–Barr virus.
  3. Endothelial damage, platelet hyperactivation and abnormal microclots may impair tissue oxygen delivery.
  4. Autonomic dysfunction is a likely contributor to orthostatic intolerance and PoTS, and neuroinflammation, including blood–brain barrier disruption, has been found in people with cognitive symptoms.
  5. Changes in the gut microbiome may also play a part.

The evidence on viral persistence is mixed. Two randomised trials of the antiviral nirmatrelvir–ritonavir (Paxlovid), including one of 959 adults treated for up to 25 days, found no benefit for Long COVID symptoms.[19][20]

Relevance for rehabilitation: muscle and post-exertional malaise

People with Long COVID consistently show lower peak oxygen uptake and power output during exercise testing than matched controls, and this appears to be driven mainly by peripheral, muscle-level factors rather than heart or lung impairment.[7] In a study of people with Long COVID and PEM, muscle biopsies showed reduced mitochondrial capacity and amyloid-containing deposits, and these abnormalities worsened after an exercise challenge.[21] Current evidence suggests that the mechanisms behind reduced exercise capacity differ from those driving PEM, so improving fitness cannot be assumed to resolve PEM. There is also substantial overlap in presentation and proposed mechanisms between Long COVID and ME/CFS, in which PEM is a core diagnostic criterion.[7]

Clinical Presentation

Long COVID is multisystem, heterogeneous and often episodic. It can be continuous, relapsing and remitting, or progressive.[22] Common symptoms include fatigue, breathlessness, muscle or joint pain and impaired sleep. Some symptoms tend to occur together, for example orthostatic intolerance (including PoTS), PEM, or a presentation consistent with ME/CFS.[23]

Post-exertional malaise (PEM)

Post-exertional malaise is a worsening of a person's Long COVID symptoms and function after physical, cognitive, or emotional exertion that they would have tolerated before becoming ill.[24] Three features distinguish it from ordinary tiredness after activity: (1) the response is out of proportion to the effort and can follow minimal exertion; (2) onset is often delayed, typically within 48 hours; (3) and recovery is prolonged, lasting days, weeks, or months.[7][24] The threshold that triggers PEM differs between people and can change from day to day.[7] An estimated 50–80% of people with Long COVID experience PEM.[7][25] The term post-exertional symptom exacerbation (PESE) is also used, particularly in the physiotherapy literature.

Orthostatic intolerance

In a UK multicentre study of 277 people attending Long COVID clinics, 47% reported a history of orthostatic intolerance symptoms and 52% developed symptoms during a 10-minute NASA Lean Test. Orthostatic hypotension on the test was no more common than in healthy volunteers (8% versus 10%).[26]

Function and quality of life

In a Canadian cohort of 360 adults, people with Long COVID had lower physical capacity than matched controls over 6 months, including on the 6-minute walk test and Short Physical Performance Battery. Their improvements did not reach clinically meaningful levels, except for fatigue. Baseline fatigue and daily step count predicted health-related quality of life at 6 months.[27]

Diagnostic Procedures

Long COVID is a clinical diagnosis based on history and examination. There is no validated diagnostic test or biomarker.[7] A positive test for the original infection is not required.[28]

In practice, diagnosis rests on four elements. The first is a history of confirmed, probable or suspected SARS-CoV-2 infection; this can include infections that were never tested, as testing was not always available.[29][30][28] The second is timing: symptoms that continue or develop after the acute infection, for 4 weeks or more (NICE) or around 3 months or more (WHO and NASEM).[29][30][28] The third is a symptom pattern consistent with Long COVID, including its fluctuating or relapsing course, together with its impact on daily function. The fourth is assessment for other conditions that could explain or coexist with the symptoms.[29]

Research has identified candidate blood markers reflecting immune and inflammatory changes, endothelial damage, metabolic disruption and clotting abnormalities, but none has been validated for diagnosis, and different subtypes of Long COVID may need different markers.[7] Routine investigations are therefore used to identify other causes and complications rather than to confirm Long COVID, and normal results do not mean the person's symptoms are not real.

Medical investigations

NICE recommends that initial investigations in primary or community care may include blood tests (full blood count, kidney and liver function, C-reactive protein, ferritin, B-type natriuretic peptide and thyroid function) and an exercise tolerance test suited to the person's ability, such as the 1-minute sit-to-stand test, recording breathlessness, heart rate and oxygen saturation. A chest X-ray is recommended by 12 weeks if respiratory symptoms continue, although a normal X-ray does not rule out lung disease.[29]

Urgent referral is needed for red flags such as severe hypoxaemia or oxygen desaturation on exercise, or cardiac chest pain.[29]

Rehabilitation assessment

Before recommending physical activity or exercise, World Physiotherapy advises screening for four factors: PEM, cardiac impairment, exertional oxygen desaturation and orthostatic intolerance.[31] For PEM, ask about symptom patterns after exertion; the DePaul Symptom Questionnaire–Post-Exertional Malaise (DSQ-PEM) can support screening.[32][33] For cardiac impairment, ask about chest pain, palpitations and syncope, and refer for medical assessment before exercise if suspected. Exertional desaturation can be checked during the exercise tolerance test described above, and orthostatic intolerance with the NASA Lean Test or an active stand test.[34]

UK clinic studies recommend offering the NASA Lean Test to all people with Long COVID, whatever their symptoms, because self-reported dizziness or palpitations did not reliably predict an abnormal result.[26][34] Because exertional tests can cause delayed symptom exacerbation, assessment should be planned to avoid triggering PEM: spread it across sessions where needed, and ask about symptoms over the following 24–72 hours. Two-day cardiopulmonary exercise testing (CPET) can objectively assess exercise capacity and post-exertional symptom exacerbation, but it is mainly used in research and specialist settings.[35]

Outcome Measures

No single measure captures Long COVID. Combine a condition-specific measure with measures matched to the person's main problems, and choose performance tests with PEM in mind. See the Outcome Measures Database for links.

Differential Diagnosis

The NICE and WHO definitions require that symptoms are not explained by an alternative diagnosis.[4][5] The NASEM definition notes that Long COVID can also coexist with other diagnosable conditions.[6] In practice, this means looking for treatable alternative or co-existing causes, without assuming that persistent symptoms are "just" Long COVID, and without dismissing them when tests are normal.

Category Conditions to consider
Cardiorespiratory
  • Myocarditis or pericarditis
  • Pulmonary embolism
  • Heart failure
  • Arrhythmia
  • Interstitial lung disease
  • Poorly controlled asthma or COPD
Haematological, metabolic and endocrine
  • Anaemia
  • Iron or vitamin B12 deficiency
  • Thyroid disease
  • Diabetes
  • Perimenopause or menopause[11]
Neurological
  • Stroke or transient ischaemic attack
  • Other causes of cognitive impairment
  • Peripheral or small fibre neuropathy
  • Sleep disorders such as obstructive sleep apnoea
Autoimmune and inflammatory New-onset autoimmune disease, which has been reported more often after SARS-CoV-2 infection[7]
Mental health Depression, anxiety and post-traumatic stress, which may coexist with Long COVID rather than explain it
Other fatiguing and post-infection conditions
  • ME/CFS (some people with Long COVID meet ME/CFS criteria)
  • Fibromyalgia
  • Other post-viral syndromes
Other
  • Medication side effects
  • Deconditioning (which does not explain PEM)
  • Malignancy where there are features such as unexplained weight loss

Refer urgently for red flags such as severe hypoxaemia or oxygen desaturation on exertion and cardiac chest pain,[4] as well as other features that need same-day medical assessment, such as syncope or new focal neurological signs.

Management / Interventions

Principles

Management should be person-centred and multidisciplinary, individualised to the person's symptoms, goals and fluctuations.[4] Safety comes first: rehabilitation should not worsen symptoms, which means screening for PEM, cardiac impairment, exertional desaturation and orthostatic intolerance before recommending physical activity, and monitoring for delayed responses.[31][38] People living with Long COVID are experts in their own condition, so clinicians should listen, believe the symptoms reported, use shared decision-making and avoid blaming people for setbacks.[38] There is currently no cure, and care is symptomatic and supportive.[7][16]

Evidence for interventions

A living systematic review found moderate certainty evidence that cognitive behavioural therapy (CBT) and physical and mental health rehabilitation probably improve Long COVID symptoms. It found no compelling evidence for the other interventions studied, including inspiratory muscle training, transcranial direct current stimulation, hyperbaric oxygen, and coenzyme Q10.[39] No antiviral or other drug has yet shown clear benefit in a well-powered randomised trial, and trials of nirmatrelvir–ritonavir were negative.[19][20] The role of exercise remains debated, partly because many trials did not assess PEM.[7] A large US platform trial (RECOVER-ENERGIZE) is now testing cardiopulmonary rehabilitation for people without significant PEM, and structured activity pacing for people with PEM; its pacing intervention is the first to be tested in a randomised trial in Long COVID.[40]

A PEM-informed approach to activity and exercise

  1. Screen first. Assess for PEM, cardiac impairment, exertional desaturation and orthostatic intolerance.[30]
  2. If PEM is present: pacing and energy management. Pacing means planning and balancing physical, cognitive and emotional activity with rest, so that the person stays within their energy limits and avoids triggering PEM.[41][42] Pacing should be symptom-contingent (guided by symptoms) rather than quota-contingent (fixed increases towards targets), and graded exercise therapy should not be used.[43] Heart rate monitoring can support pacing by giving real-time feedback. Approaches vary: some resources estimate an upper limit from age-predicted maximum heart rate, while others use resting heart rate as the benchmark. The evidence is limited, and heart rate thresholds can mislead in people with PoTS.[44]
  3. 3. If PEM is absent: individualised, monitored exercise-based rehabilitation.

Start below the person's capacity, progress slowly, and monitor symptoms for 24–72 hours after sessions. If symptoms flare, reduce or pause activity and reassess for PEM.

Symptom-specific approaches

Problem Approaches
Fatigue and PEM
  • Pacing; energy conservation
  • Activity planning and prioritisation
  • Rest
  • Heart rate monitoring where helpful[45][42]
Orthostatic intolerance and PoTS
  • Education
  • Avoiding prolonged standing
  • Referral for medical management
  • Increasing fluid and salt intake can improve symptoms (with medical advice)[7]
Breathlessness
  • Assess for exertional desaturation and other causes
  • Breathing pattern assessment and retraining where breathing pattern disorder is present
Cognitive impairment
  • Education, self-management strategies and cognitive exercises[45]
  • A randomised trial has tested cognitive and affective psychoeducation[46]
Smell and taste Education and skills training in olfactory training[45]
Voice Voice rest and education on vocal behaviours[45]
Mental health
  • CBT and psychological support[39]
  • Screen for anxiety, depression and post-traumatic stress
Work and participation Phased return to work with workplace adjustments, planned around energy limits and fluctuations

Peer support

People living with Long COVID were central to first describing and naming the condition,[1] and many value peer support from others with lived experience. Clinicians can signpost people to established, moderated peer support groups and national charities.

Additional Resources

Optional Reading

Video Resources for Patients

[47]
[48]
[49]

References

  1. ↑ 1.0 1.1 Perego E, Callard F, Stras L, Melville-Jóhannesson B, Pope R, Alwan N. Why we need to keep using the patient made term “Long Covid.
  2. ↑ 2.0 2.1 2.2 2.3 World Health Organization. Post COVID-19 condition (long COVID). 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/post-covid-19-condition-(long-covid) [Accessed 21 October 2026].
  3. ↑ Joli J, Buck P, Zipfel S, Stengel A. Post-COVID-19 fatigue: A systematic review. Frontiers in psychiatry. 2022 Aug 11;13:947973.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the long-term effects of COVID-19. 2024. Available from: https://www.nice.org.uk/guidance/ng188 [Accessed 21 October 2026].
  5. ↑ 5.0 5.1 5.2 5.3 World Health Organization. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021. World Health Organization; 2021 Oct 4.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; Committee on Examining the Working Definition for Long COVID. A Long COVID Definition: A Chronic, Systemic Disease State with Profound Consequences. Edited by Ilana Goldowitz et. al., National Academies Press (US), 9 July 2024.
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 Faghy MA, Wüst RC, Altmann DM, Ashton RE, McMullen SB, Duncan R, Ewing AG, Hausmann E, Gupta S, Hornig M, Joffe D. Current status and future perspectives on the mechanistic and pathophysiological understanding of long COVID. Communications medicine. 2026 Apr 29;6(1):255.
  8. ↑ ME Research UK. The prevalence of long COVID. Available from: https://www.meresearch.org.uk/the-prevalence-of-long-covid-summary/ (accessed 21 October 2026).
  9. ↑ Shi J, Lu R, Tian Y, Wu F, Geng X, Zhai S, Jia X, Dang S, Wang W. P-1669. Prevalence of and Factors Associated with Long COVID among US Adults: A Nationwide Survey. InOpen Forum Infectious Diseases 2026 Jan (Vol. 13, No. Supplement_1, pp. ofaf695-1843). US: Oxford University Press.
  10. ↑ Tsampasian V, Elghazaly H, Chattopadhyay R, Debski M, Naing TK, Garg P, Clark A, Ntatsaki E, Vassiliou VS. Risk factors associated with post− COVID-19 condition: a systematic review and meta-analysis. JAMA internal medicine. 2023 Jun;183(6):566-80.
  11. ↑ 11.0 11.1 Shah DP, Thaweethai T, Karlson EW, Bonilla H, Horne BD, Mullington JM, Wisnivesky JP, Hornig M, Shinnick DJ, Klein JD, Erdmann NB. Sex differences in long COVID. JAMA network open. 2025 Jan 22;8(1):e2455430.
  12. ↑ Ballouz T, Menges D, Anagnostopoulos A, Domenghino A, Aschmann HE, Frei A, Fehr JS, Puhan MA. Recovery and symptom trajectories up to two years after SARS-CoV-2 infection: population based, longitudinal cohort study. Bmj. 2023 May 31;381.
  13. ↑ Thaweethai T, Donohue SE, Martin JN, Hornig M, Mosier JM, Shinnick DJ, Ashktorab H, Atieh O, Blomkalns A, Brim H, Chen Y. Long COVID trajectories in the prospectively followed RECOVER-Adult US cohort. Nature communications. 2025 Nov 17;16(1):9557.
  14. ↑ Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, mechanisms and recommendations. Nature Reviews Microbiology. 2023 Mar;21(3):133-46.
  15. ↑ 15.0 15.1 National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the long-term effects of COVID-19. 2024. Available from: https://www.nice.org.uk/guidance/ng188 [Accessed 21 October 2026].
  16. ↑ 16.0 16.1 Greenhalgh T, Sivan M, Perlowski A, Nikolich JŽ. Long COVID: a clinical update. The Lancet. 2024 Aug 17;404(10453):707-24.
  17. ↑ Subramanian A, Nirantharakumar K, Hughes S, Myles P, Williams T, Gokhale KM, Taverner T, Chandan JS, Brown K, Simms-Williams N, Shah AD. Symptoms and risk factors for long COVID in non-hospitalized adults. Nature medicine. 2022 Aug;28(8):1706-14.
  18. ↑ YouTube. Long COVID Explained: Symptoms, Causes, and What We Know Now | Dr. Gary Kaplan. Available from: https://www.youtube.com/watch?v=TwzsHv0sb18 [last accessed 25 October]
  19. ↑ 19.0 19.1 Geng LN, Bonilla H, Hedlin H, Jacobson KB, Tian L, Jagannathan P, Yang PC, Subramanian AK, Liang JW, Shen S, Deng Y. Nirmatrelvir-ritonavir and symptoms in adults with postacute sequelae of SARS-CoV-2 infection: the STOP-PASC randomized clinical trial. JAMA Internal Medicine. 2024 Sep;184(9):1024-34.
  20. ↑ 20.0 20.1 Baden LR, Shah NS, Liu ST, Cohen J, Moy J, Kumar A, McComsey GA, Chen P, Floris-Moore M, Singer NG, Fernandez I. Nirmatrelvir–ritonavir targeting viral persistence in post-COVID-19 condition (long COVID) in the USA (RECOVER-VITAL): a randomised, double-blind, placebo-controlled, phase 2 trial. The Lancet Infectious Diseases. 2026 Aug 31.
  21. ↑ Appelman B, Charlton BT, Goulding RP, Kerkhoff TJ, Breedveld EA, Noort W, Offringa C, Bloemers FW, van Weeghel M, Schomakers BV, Coelho P. Muscle abnormalities worsen after post-exertional malaise in long COVID. Nature communications. 2024 Jan 4;15(1):17.
  22. ↑ National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; Committee on Examining the Working Definition for Long COVID. A Long COVID Definition: A Chronic, Systemic Disease State with Profound Consequences. Edited by Ilana Goldowitz et. al., National Academies Press (US), 9 July 2024.
  23. ↑ World Health Organization. Post COVID-19 condition (long COVID). 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/post-covid-19-condition-(long-covid) [Accessed 21 October 2026].
  24. ↑ 24.0 24.1 Board on the Health of Select Populations, Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: redefining an illness.
  25. ↑ Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA. Development of a definition of postacute sequelae of SARS-CoV-2 infection. Jama. 2023 Jun 13;329(22):1934-46.
  26. ↑ 26.0 26.1 Lee C, Greenwood DC, Master H, Balasundaram K, Williams P, Scott JT, Wood C, Cooper R, Darbyshire JL, Gonzalez AE, Davies HE. Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study. Journal of medical virology. 2024 Mar;96(3):e29486.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 27.5 Salmam I, Desmeules F, Perreault K, Zahouani I, Beaulieu-Bonneau S, Campeau-Lecours A, Paquette JS, Deslauriers S, Tittley J, Drouin G, Best K. Trajectories of Physical Disabilities Over 6 Months in Patients With Long COVID. Physical Therapy. 2025 Aug;105(8):pzaf091.
  28. ↑ 28.0 28.1 28.2 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; Committee on Examining the Working Definition for Long COVID. A Long COVID Definition: A Chronic, Systemic Disease State with Profound Consequences. Edited by Ilana Goldowitz et. al., National Academies Press (US), 9 July 2024.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the long-term effects of COVID-19. 2024. Available from: https://www.nice.org.uk/guidance/ng188 [Accessed 21 October 2026].
  30. ↑ 30.0 30.1 30.2 World Health Organization. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021. World Health Organization; 2021 Oct 4.
  31. ↑ 31.0 31.1 World Physiotherapy. World Physiotherapy response to COVID-19, Briefing paper 9. Available from: https://world.physio/sites/default/files/2021-06/Briefing-Paper-9-Long-Covid-FINAL-2021.pdf (accessed 25 October 2026).
  32. ↑ 32.0 32.1 Cotler J, Holtzman C, Dudun C, Jason LA. A brief questionnaire to assess post-exertional malaise. Diagnostics. 2018 Sep 11;8(3):66.
  33. ↑ 33.0 33.1 Kuczyk C, Nöhre M, Herrmann-Lingen C, Stolz M, Krauth C, Brähler E, Jason LA, De Zwaan M. Reliability and validity of the German version of the DePaul symptom questionnaire post-exertional malaise (DSQ-PEM). Frontiers in Psychiatry. 2025 Sep 4;16:1647040.
  34. ↑ 34.0 34.1 Isaac RO, Corrado J, Sivan M. Detecting orthostatic intolerance in long COVID in a clinic setting. International Journal of Environmental Research and Public Health. 2023 May 12;20(10):5804.
  35. ↑ Thomas C, Kudiersky N, Ansdell P, Ashton RE, Brown C, Bewick T, Carr J, Hume E, Spillane P, Pastorio E, Owen R. Submaximal 2‐day cardiopulmonary exercise testing to assess exercise capacity and post‐exertional symptom exacerbation in people with long COVID. Experimental Physiology. 2026 Feb;111(2):435-48.
  36. ↑ Horton M, Smith AB, Milne R, Winch D, Rayner C, Halpin S, O'Connor R, Rocha Lawrence R, Greenwood DC, Bakerly ND, Evans R. Large‐Scale Psychometric Assessment and Validation of the Modified COVID‐19 Yorkshire Rehabilitation Scale Patient‐Reported Outcome Measure for Long COVID or Post‐COVID Syndrome. Journal of Medical Virology. 2026 Feb;98(2):e70816.
  37. ↑ Klok FA, Boon GJ, Barco S, Endres M, Geelhoed JM, Knauss S, Rezek SA, Spruit MA, Vehreschild J, Siegerink B. The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after COVID-19. European respiratory journal. 2020 Jul 2;56(1).
  38. ↑ 38.0 38.1 DeMars J, Brown DA, Angelidis I, Jones F, McGuire F, O’Brien KK, Oller D, Pemberton S, Tarrant R, Verduzco-Gutierrez M, Gross DP. What is safe long COVID rehabilitation?. Journal of Occupational Rehabilitation. 2023 Jun;33(2):227-30.
  39. ↑ 39.0 39.1 Zeraatkar D, Ling M, Kirsh S, Jassal T, Shahab M, Movahed H, Talukdar JR, Walch A, Chakraborty S, Turner T, Turkstra L. Interventions for the management of long covid (post-covid condition): living systematic review. Bmj. 2024 Nov 27;387.
  40. ↑ Friedly J, Bateman L, Berdan LG, Casaburi R, Erdmann N, Felker GM, Itchon-Ramos N, Keteyian SJ, MacIntyre N, O’Brien L, Reist C. Rationale and Design of RECOVER-ENERGIZE: A Platform Clinical Trial of Interventions for Exercise Intolerance With and Without Post-exertional Malaise in Long COVID. medRxiv. 2026 Jun 3.
  41. ↑ World Health Organization. Clinical management of COVID-19: Living guideline, 23 June 2022. World Health Organization; 2022 Jun 22.
  42. ↑ 42.0 42.1 McMaster University. Long COVID (CAN-PCC). Available from: https://macgrade.mcmaster.ca/guidelines/home-canpcc/ (accessed 25 October 2026).
  43. ↑ National Institute of Health and Care Excellence. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. Available from: https://www.nice.org.uk/guidance/ng206 (accessed 25 October 2026).
  44. ↑ Emerge Australia. Beyond Basics: Advanced Pacing and Heart Rate Monitoring in ME/CFS. Available from: https://education.emerge.org.au/wp-content/uploads/2026/04/Advanced-Pacing-HR-Monitoring-Emerge-Webinar-Aug-2026.pdf (accessed 25 October 2026).
  45. ↑ 45.0 45.1 45.2 45.3 World Health Organization. Clinical management of COVID-19: Living guideline, 18 August 2023. Available from:https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2023.2 (accessed 25 October 2026).
  46. ↑ Cabello Fernandez C, Didone V, Lesoinne A, Slama H, Fery P, Rousseau AF, Moutschen M, COVCOG group Moutschen Michel Dupuis Gilles Delrue Gaël Demoulin Valentine Goin Julien Della Libera Clara, Collette F, Willems S. Cognitive and affective psychoeducation for Long COVID: a randomized controlled trial. Brain Communications. 2025;7(6):fcaf447.
  47. ↑ Mayo Clinic. Mayo Clinic Minute: Dealing with 'brain fog' from long COVID-19. Available from: https://www.youtube.com/watch?v=NcwwYG2pgAI [last accessed 16/06/2023]
  48. ↑ Long COVID Physio. Safe Long COVID Rehabilitation. Available from: https://www.youtube.com/watch?v=4pWZg_epDkg [last accessed 16/06/2023]]
  49. ↑ Long COVID Physio. Impact of Long COVID on Day-to-Day Life. Available from: https://www.youtube.com/watch?v=QdkU2zSqiuk [last accessed 16/06/2023]

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