The COVID-19 Long-hauler

Nicole Gardner and I were able to take a continuing education course this past weekend, put on by the California Physical Therapy Associate and Mary Massery, PT, DPT, DSc on the long-term effects being seen from COVID-19 survivors. This informative program gave us both significant new knowledge and what to look for as patients come in to be seen at the clinic as COVID-19 long-haulers.

What is a long-hauler?

Let’s begin with defining what a long-hauler is first. A long-hauler is someone who tested positive for COVID-19, may have had mild to severe symptoms, and whose symptoms did not resolve after 28 days. There appears to be no specific age or severity of symptoms linked with long-haulers, 26 year old marathon runners to 80-year-old retirees are long-haulers.

In late 2020, Dr. Anthony Fauci, Chief Medical Advisor and Director of the National Institute of Allergy and Infectious Disease thought about 10% of all had COVID-19 survivors would be deemed long-haulers. Within the last week, he redacted his statement and said that closer to 20-30% of those who had COVID-19 would be deemed long-haulers, with the number probably rising higher as the disease changed and more data is collected.

20-30% of survivors are now thought to be long-haulers

20-30% of COVID-19 survivors will have long-term effects from the virus. Of the 28 million Americans that at the time of this blog have tested positive for COVID-19, 6-8 million people will be long-haulers. That is a lot of people who will suffer from the long-term effects of the virus. The difficult aspect about COVID-19 is how many different symptoms there are and how they affect people differently. They range from the more common shortness of breath and coughing, fatigue, body aches, loss of taste and smell, difficulty sleeping, headaches, and brain fog.

What are we seeing in the clinic?

As physical therapists, the most common symptoms we get complaints about in the clinic are shortness of breath, fatigue, headaches, and brain fog (difficulty concentrating). All of these symptoms can be treated within the clinic

Shortness of Breath

Depending on the severity of the symptoms, intubation may have been required at some point to help to breathe. When intubation occurs, the muscles that work to help you breathe in and out weaken. Once you no longer need help breathing from machines, and the tube comes out, the muscles that help you breathe must again work to ventilate you. These weakened muscles have a more difficult time performing the work they are supposed to do and tend to fatigue quickly. What was once easy to do, like bending down to tie a shoe, leaves a person short of breath. Also seen with COVID-19 have been some cases of pulmonary fibrosis, a scarring of the lung tissue that can lead to increased difficulty breathing and oxygenation of the blood. Talking, walking, standing, rolling over in bed all become taxing to your respiratory system when you aren’t able to breathe normally.

Physical therapy can help improve symptoms of shortness of breath. There are manual techniques, retraining of the diaphragm, breathe training, along with other treatments that are used to help facilitate improved breathing in patients. For most people, oxygen saturation levels are good, but the perception that breathing is labored gives the person the feeling that they are always short of breath. Weakness in the muscles that help to breathe causes the feeling like shortness of breath.

The Diaphragm plays a large part

A diaphragm that is weak and not functioning properly can cause problems throughout the body. A poorly functioning diaphragm causes problems with balance, neck, shoulder, and low back pain, headaches, decreased limb strength, reflux, constipation, and urinary stress incontinence, in addition to poor ventilation. 

In addition to the manual work a therapist can do to facilitate easier breathing, the use of an inspiratory muscle trainer can be useful when conditioning the respiratory muscles. This tool is fairly inexpensive and easy to use. Simply practicing inspiration against the resistance of the trainer can help strengthen the muscles required to help make breathing less tiring. A trained therapist can help get you started with your trainer and work with you through the process to help progress you to a point where breathing is not labored, talking no longer winds you, and for some, they can sing again, even if just in the shower.


Muscle weakness both in the extremities, core, and those used for breathing contribute to the extreme fatigue some long-haulers experience. There are accounts of people who have a hard time having enough energy to walk 10 feet to the bathroom without needing to go back to bed and rest. The deconditioning and fatigue from COVID-19 that has been seen can be assessed and treated with a physical therapist. Physical therapists will put together an individualized program that fits your needs at that exact moment in time. It is recommended to start slow, pace yourself, and listen to your body. Most long-haulers as they improve note that they feel fine while performing an activity, but once it’s complete, feel intense, extensive exhaustion. By that point, it is too late and the body is so fatigued it can’t function well.

Headaches and Brain Fog

Headaches have been reported in about 13% of those who tested positive for the COVID-19 virus and confusion and brain fog reported in 11%. We don’t have an exact reason as to why this is happening, some think it may be due to dehydration, reduced oxygen levels, and what some researchers have found, large bone marrow cells in the capillaries of the brain that restrict or occlude blood flow. Another line of thinking in part for why there is an increase in headaches and neck pain is the over-recruitment of accessory muscles used in helping one breathe. With part of the lungs damaged from COVID-19, other muscles must work harder to try and get deep breathes and functional respiratory rates.

A physical therapist has many different treatment options when it comes to helping with headaches and brain fog. Treatment may consist of manual work, facilitation of normal recruitment of the muscles that help you breathe, and mobility exercises that improve the function of your torso to allow for easier breathing.

Information surrounding COVID-19 is ever-changing. As we continue to see more data from COVID-19 survivors, our treatment methods may change and adapt to meet the current needs. For the time being, therapy can help ease the patients’ long-hauler symptoms and allow them to return to a more “normal” sense of life that they were accustomed to, before coming down with COVID-19.

If you are interested in scheduling an appointment with one of our trained therapists who deal with this, please click here. For more information on the COVID-19 Long-Hauler, listen to Molly and Nicole speak about it on the podcast Freedom Talks.

Physical Therapist at Freedom Physical Therapy Services
Molly Rittberg received her master’s degree in Physical Therapy in 2007 from the University of Wisconsin-Madison and went on to receive her doctorate from Rosalind Franklin University (North Chicago) in 2009. She has since worked in an outpatient orthopedic practice where she worked with patients of all ages, injuries and disabilities. She has a wide variety of experiences including knee, ankle, foot and shoulder injuries, post-operative conditions, spinal rehabilitation and peripheral neuropathies.