COVID-19 “Long-haulers”: Physical Therapy – The Treatment of Choice

By Dr. John R. Mishock, PT, DPT, DC

Researchers estimate about 10% of COVID-19 patients become “COVID long-haulers” (Rubin, JAMA, 2021). “Long-haulers” are people who experience persisting symptoms of COVID-19 long after the infection is defeated. The condition can affect both young and old with very mild to severe symptoms. COVID-19 has far-reaching pathology, potentially affecting the lungs, heart, brain, stomach, kidneys, muscles, joints, or other organs. COVID-19 enters human cells via the ACE 2 receptor (a protein on the human cell). Many organs and tissues throughout the body have an abundance of ACE2 receptors. For example, the nerves that allow smell (olfactory bulb) have a high density of ACE-2 receptors. When infected, this leads to the common symptom of the loss of smell.

It is not known why some develop long-term symptoms; however, it appears the variation in viral load and the individual’s immune response appears to play a role in the chronicity. Those who have more organ systems involved initially may be more predisposed. (Baig, Asc Chem Neurosci, 2020)

Symptoms of “Long-haulers” include coughing, fatigue, body aches, joint pain, shortness of breath, loss of taste or smell, difficulty sleeping, headaches, brain fog, tremors, confusion, limb stiffness, muscle pain, weakness, and difficulty with exercise and endurance. (Baig, Asc Chem Neurosci, 2020, Johns Hopkins, 2020, CDC, 2021)

The vast majority of “long-haulers” eventually test negative for COVID-19 but continue to have symptoms. One standard theory is that the virus possibly remains in their bodies in some small form. Another idea is the individual’s immune system continues to overreact even though the acute infectious period is over, producing inflammation and scar tissue to the involved organs. An exaggerated response of the body’s immune system (cytokine storm) is typical in patients with severe acute symptoms. There is a growing body of literature supporting the theory that the mitochondrial (energy powerhouse of the cell) may become dysfunctional following COVID-19 infection. The dysfunctional mitochondria lead to a lack of energy production, producing symptoms of; fatigue, weakness, deconditioning, and much more.

It is unknown if there will be permanent damage, but early treatment in the first 30 days post-infection may be critical to prevent chronicity. The National Institute for Health and Care Excellence recommends a progressive rehabilitation program to be initiated within the first 30 days (post-acute phase) to have the most significant impact on recovery.

In the lungs, a prospective cohort study of “long-haulers” showed a significant effect, with 28% of patients having difficulty breathing, reduced exercise capacity, and abnormal chest radiographs at 6-12 months. (Hui et al. Chest, 2021)

In the heart, cardiac complications include inflammation and scarring of the heart muscle (myocarditis). If that individual participates in high-level sports or physically demanding occupations, advanced testing (ECG, echocardiogram, cardiopulmonary exercise testing, and or cardiac MRI) may be required to return to activity. If there is confirmed myocarditis, the individual may need a 3-6 month period of complete rest followed by a progressive rehabilitation program.

In the brain, COVID-19 affects the neurological system, potentially producing small blood clots causing “mini-strokes”. It also can affect the peripheral nerves causing numbness, tingling, and weakness (Johns Hopkins, 2021)

How can Physical Therapy help “long-haulers”?

Your physician should recommend physical therapy treatment within 30 days of continued symptomatology. Your doctor level trained physical therapist will do a complete functional assessment to determine residual musculoskeletal, cardiac, and neurological deficits. The physical therapist will explain the etiology and make a plan with you to optimize recovery. Treatment options may include; manual therapy to involved muscles and joints, stretching of tight or impaired muscles, a progressive-resistance exercise training program based on the individual’s weakness patterns, cardiovascular reconditioning to improved endurance, vestibular rehabilitation to improve dizziness, vertigo, and other neurological changes, diaphragmatic breathing to improve lung capacity and endurance. (Wang et al., Am J Phys Med Rehabil, 2020)

For those individuals who have lost the sense of smell, “smell therapy” can significantly improve symptoms. Multiple studies have found training smell by taking deep sniffs of four different aroma categories; rose (flowery), lemon (fruity), cloves (aromatic), and eucalyptus (resin) can make a difference. The patient sniffs for 10 seconds of each substance twice a day for 12 weeks. One study used other aromas for training, such as; vanilla, orange, cinnamon, menthol, and banana. (Int For of Aller & Rhino, 2018, Larynx Invest Otolar, 2017)


Can nutrition and supplements help “long-haulers”?

In optimizing recovery from illness or injury, good nutrition is essential to maximize the body’s healing opportunity. Diets with ample fruits and vegetables and lean meats are critical to optimal health, while avoiding ultra-processed foods which increase inflammation and cellular dysfunction. Nutraceutical supplements can complement a good diet, potentially enhancing COVID-19 “long-hauler” recovery.

Creatine Monohydrate (creatine): Creatine monohydrate is a naturally occurring non-protein amino acid found primarily in red meat and seafood. Creatine works in the mitochondria to create the energy needed for cellular function. Studies have shown the effective use of creatine to enhance sports performance by building and protecting muscle. It also can act as a neuroprotector in conditions such as; traumatic brain injury, neurodegenerative diseases (Alzheimer’s, Parkinson’s diseases, brain injury), and cerebral ischemia (strokes). (Arch Phys. Med rehab., 2003) (Mol cell biochem, 2003). The recommended dose is 5 mg/daily.

CoQ10/MitoQ: A CoQ10 analog, MitoQ (mitoquinol mesylate) the more bioavailable form of CoQ10) is a powerful antioxidant and energy producer. It reduces oxidative damage (free radical) to the mitochondria preventing cellular damage. Studies show significant physical function improvements in individuals with chronic fatigue versus controls. (Wood, Science Direct, 2020) The recommended dose is MitoQ 10-20 mg per day.

Zinc: Zinc is found in meats, seafood, beans, nuts, and seeds. Zinc regulates inflammatory activity, having antiviral and antioxidant functions. Studies have shown that zinc reduces acute respiratory infections by 35% and shortens flu-like symptoms by two days, and improves the rate of recovery. The recommended dose ranges from 20-92 mg/week. (Fitzgerald et al. Infect Dis, 2017)

Vitamin D: It is a fat-soluble vitamin that plays a role in immune modulation, antioxidant, and antiviral responses. It may reduce or suppress the “cytokine storm,” which is the hyper-immune response seen in COVID-19. Older individuals and those with limited sun exposure are most at risk for deficiency. (Mendes et al. Front Immunol, 2019)

Vitamin C: It can protect against infection by supporting various immune cells (T-cells). It also is anti-inflammatory and antioxidant binding free radicals reducing oxidative stress. The recommended dose is 1 to 3 g/day.

Turmeric/Curcumin: This supplement has broad biological actions, antibacterial, antiviral, antifungal, antioxidant,a nad anti-inflammatory. It may reduce virus entry into the cell at the ACE-2 receptor. (Hosseini et al. Phytother Res, 2020, Dong et al. Appl Nano Mater, 2018)

Other anti-oxidants to consider; garlic, selenium, quercetin


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Dr. Mishock is one of only a few clinicians with doctorate level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has also authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “ The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon.

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