Physical activity advice
Physical activity advice in long COVID
Spending time in hospital and also being ill at home with COVID-19 over a long period of time can result in a significant reduction in your muscle strength and endurance.
Exercise is very important for regaining your muscle strength and endurance BUT this needs to be safe and managed alongside other long COVID symptoms.
Activities around the house and gentle short walks whilst pacing are considered safer whilst you are recovering before returning to exercise.
You might experience worsening of fatigue and other symptoms (described as “crashing” or “relapse”) after minimal exertion. This is described in scientific terms as “post-exertional malaise”, or PEM for short. The worsening typically is felt hours or days after physical or mental exertion. Recovery normally takes 24 hours or longer and can affect your energy levels, concentration, sleep and memory, and cause muscle/joint pains and flu-like symptoms.
If you experience PEM, you need to avoid exercise and activities that cause PEM and aim to conserve your energy. If you don’t experience PEM, you can gradually increase your level of activity or exercise to improve your fitness levels. You could use the Borg Rating of Perceived Exertion (RPE) Category Ratio CR-10 Scale as a rough guide to gradually increasing your activity level. This scale is a subjective assessment of how hard you feel you’re working on a scale from 0 (no exertion at all) to 10 (maximum exertion).
The same activity will have different RPE scores in different people or at different times. For example, you may score slow walking as RPE 1 (extremely light) but this may be scored as 4 (somewhat hard) by another person, or by you on a different day. You can write down your daily activities and their RPE scores to monitor your condition and guide you on how you can increase your activity level.
Using the BORG scale will help you regulate your exertion and develop a good understanding of the level of activity or exercise that you should be working at. It is a good tool to help you understand any symptoms of breathlessness you might have.
- The strength of your breathing muscles, heart and circulation
- The strength of your arms and leg muscles
- Your energy levels
- Your wellbeing, independence and confidence
- Anxiety or depression
- Stress levels and blood pressure
- Risk of falling by improving your balance
- The risk of developing other problems associated with bed rest such as chest infections, bed sores, blood clots, reduced mobility and weakness
How to use the BORG scale during activity and exercise
Next you will see a copy of the BORG scale, you can use it to understand how hard you are working and your feelings of breathlessness whilst undertaking any physical activity and during exercise.
This scale is based on how effortful your breathing feels at rest and during activity or exercise.
Using this scale during activity and exercise will really give you guidance and a greater understanding about the safe level to challenge yourself.
If you are suffering from on-going fatigue, please seek advice from a physiotherapist before getting back to ‘strenuous’ exercise.
Fatigue and exercise need to be carefully considered and phased to prevent Post Exertional Malaise (PEM) and a ‘relapse’ of your symptoms.
PEM symptoms include a marked physical and or mental fatigue in response to increased activity/exercise and can be debilitating and cause a relapse.
The exhaustion felt maybe immediate after the activity/exercise or maybe delayed by hours or days. Recovery normally takes 24 hours or longer and can affect your fatigue levels, concentration, sleep, memory and can cause muscle/joint pains and flu like symptoms.
To avoid PEM or find out more about managing fatigue please refer to the ‘Fatigue’ page on this website.
If you experiencing fatigue symptoms after exercise then we recommend:
- Monitor your heart rate as you exercise and introduce new exercises
- Monitor your rate of perceived exertion using the Borg Rating of Perceived Exertion Scale
- Keep your heart rate at less than 60% of your maximal heart rate
- You can monitor your heart rate by taking your pulse or you may have a phone or smart watch that can do this for you
- If you cannot confidently do this, then continue to use Borg Rating of Perceived Exertion Scale
If you are suffering from chest pain, palpitations, severe breathlessness or feel faint then please seek advice from a physiotherapist before starting any exercise programme.
A physiotherapist will ensure that you have had the necessary investigations prior to starting exercises.
If you have a diagnosis of any cardiac problems or autonomic nervous system problems such as Postural Orthostatic Tachycardia Syndrome, you may need a more individualised exercise programme than the suggestions in the following pages.
Phases of exercise
You should consider your return to exercise in 5 phases; the following sections describe these phases and give suggestions.#
Stay at each phase for a minimum of seven days before progressing to the next. Drop back a phase if you find it difficult or experience setbacks in your symptoms. If you experience any “red flag” symptoms such as chest pain or dizziness, you should stop immediately and not restart your exercise programme until you have been seen by a health care professional or physiotherapist.
Phase 1 - Preparation for return to exercise
Types of exercise: Gentle walking, breathing exercises, flexibility and stretching.
Relaxed tummy breathing
- Make sure you are in a comfortable position with your head and back supported and your shoulders and upper chest relaxed.
- Place one hand on your tummy – feel your tummy rise and expand as you breathe in and relax back down as you breath out.
- Rest and wait for your next breath to come.
- Breathe gently when practicing; there should only be a slight movement of your tummy at rest.
Stretching your muscles can be done sitting or standing. Each stretch should be performed gently, and you should hold each one for 15–20 seconds.
Reach your right arm up to the ceiling and then lean over to the left slightly; you should feel a stretch along the right side of your body. Repeat on the other side.
Put your arm out in front of you. Keeping your arm straight, bring it across your body at shoulder height, using your other hand to squeeze your arm to your chest so you feel a stretch around your shoulder. Repeat on the opposite side.
Sit on the edge of a chair with your leg out straight
in front of you with your heel resting on the ground.
Place your hands on your other thigh as support.
Sitting as tall as you can, bend slightly forward at
your hips until you can feel a slight stretch down the
back of the leg that is stretched out. Repeat on the
Stand with your feet apart, lean forward onto a wall and step one leg behind you. Bend your front knee, keeping your back leg straight and your heel on the floor. You should feel a stretch in the back of your lower leg. Repeat on the opposite side.
Stand up and hold onto something sturdy for support.
Bend one leg up behind you, using the hand on the
same side to hold your ankle or the back of your leg.
Take your foot up towards your bottom until you feel a
stretch along the front of your thigh. Repeat on the
Phase 2 - Low intensity activity
Types of exercise: Walking, light household/garden tasks, light yoga. If your RPE score for any of these is more than 3, do not do them in this phase.
If you can tolerate RPE scores of 2–3, you can gradually increase the time spent in exercises by 10–15 minutes per day. You’ll need to spend at least seven days in this phase without crashing (post-exertional malaise (PEM)) before progressing to the next level.
Light Yoga is a form of stretching, breathing control and relaxation that has been found to be beneficial during your recovery from COVID. Yoga is shown to assist with the lymphatic system that helps to:
- Remove toxins from the body
- Increase flexibility in the thoracic region (where your heart and lungs are) that can become weak and stiff during illness and resulting inactivity
Iyengar Yoga UK have developed a COVID-19 yoga programme, downloadable here.
Phase 3 - Moderate intensity aerobic and strength exercises
Types of exercise: brisk walking, going up and down stairs, jogging, introducing inclines, resistance exercises.
If your RPE score for any of these is more than 5, do not do them in this phase.
Exercise 1: Bicep curl
With your arms by your side, hold a weight in each hand, such as a tin of food, with your palms facing upwards. Gently lift the lower part of both arms (bending at the elbows) bringing the weights up towards your shoulders, and slowly lower back down again. You can do this exercise sitting or standing.
Exercise 2: Wall push off
Place your hands flat against a wall at shoulder height,
with fingers facing upwards, and your feet about 30 cm away from the wall. Slowly lower your body towards the wall by bending your elbows, then gently push away from the wall again, until your arms are straight.
Exercise 3: Arm raises to the side
Hold a weight in each hand with your arms by your sides and your palms facing inwards towards your body. Raise both arms out to the side, up to your shoulder level (but not higher), and slowly lower back
Exercise 1: Sit to stand
Sit in a chair with your feet a hip-width apart. With your arms by your side or crossed over your chest, slowly stand up, hold the position for the count of three, and slowly sit back down onto the chair.
Exercise 2: Knee straightening
Sit in a chair with your feet together. Straighten one knee and hold your leg out straight for a moment, then slowly lower it. Repeat with your other leg. Increase the time holding your leg out straight to a count of three,
Exercise 3: Squats
Stand with your back against a wall or other stable surface and your feet slightly apart. Move your feet about 30 cm away from the wall. Keeping your back against the wall, or holding on to a chair, slowly bend your knees a short distance; your back will slide down the wall. Keep your hips higher than your knees. Pause for a moment before slowly straightening your knees again.
Exercise 4: Heel raises
Rest your hands on a stable surface (such as a chair) to support your balance, but do not lean on them. Slowly rise up on to your toes, and slowly lower back down again.
Phase 4 - Moderate intensity aerobic and strength exercises with co-ordination and functioning skills
Types of exercise: Cycling, swimming, jogging, racket sports, Zumba classes, dance classes
If your RPE score for any of these exercises is more than 7, do not do them in this phase.
Phase 5 - Return to your baseline excercises
You are now able to complete your usual pre COVID regular exercise/activity regime.
- Spend a minimum of seven days at each phase
- Drop back a phase if you have difficulty
- Only exercise if you feel recovered from the previous day and have no return of symptoms and no new symptoms
- Choose exercises that you enjoy. You are more likely to do them and they will help to improve your mental wellbeing
- Exercises that you did prior to COVID may not be appropriate to your stage of recovery
- Doing less intensity of the same pre COVID activity may not always be the best way to approach your phased return to exercise
- Track your exercise progress using an exercise dairy on the next page.
No exercise should be painful. If you experience pain, chest pain, feel faint or dizzy during exercise you should stop immediately and not restart your exercise programme until you have been seen by your physiotherapist.